Central retinal vein occlusion associated with sildenafil citrate (viagra)

CENTRAL RETINAL VEIN OCCLUSION AFTER SILDENAFIL
CITRATE (VIAGRA) USE

Bassam Nawaiseh, MD*, Ahmed Shobaki MD*, Ahmad Hassouneh, MD*, Issam Bataineh, MD*,
Mohamed Al-Jaar, MD*

This is a report of a 31-year old male patient who presented with poor vision of his left eye of one-week duration after the use of two tablets of Sildenafil citrate (Viagra) approximately 24 hours before and 48 hours after the onset of ocular symptoms. Ocular examination was consistent with the diagnosis of central retinal vein occlusion. There was no history of systemic diseases or ocular risk factors for central retinal vein occlusion. To the best of our knowledge, the young man, described here, is the first to be reported to have fulminant central retinal vein occlusion after Sildenafil use make this case worth reporting. This paper discusses the history, physical examination, and investigations done for the patient. JRMS June 2006; 13(1): 46-47
have any medical illnesses or ocular diseases. Ocular Sildenafil is used primarily for management of physical examination revealed that the vision of the right erectile dysfunction. Ocular side effects are uncommon, eye was 6/6 and of the left eye was hand movement. dosage dependent and thus far all have been fully There was left relative afferent papillary defect. Fundus reversible. These include changes in color and light examination showed marked tortuosity and engorgement perception, blurred vision, ERG changes, conjunctival of the retinal veins, extensive retinal hemorrhages hyperemia and hemorrhages, ocular, pain, photophobia involving posterior pole and peripheral retina, severe and mydriasis. Some of these side effects were not optic disc edema and hyperemia. Ophthalmoscopy of the proven to be drug related. Also ocular side effects are right eye revealed normal optic disc and normal retina. directly proportional to blood drug level, and usually Intraocular pressure (IOP) measured by applanation starts at 15-30 minutes and usually peak one hour after tonometry was 12 mmHg. General physical examination ingestion of the drug. Drug half-life is 4 hours (1).
did not reveal any systemic diseases and his blood Anterior ischemic optic neuropathy (2,3), pupil-sparing
pressure was 120/80 mmHg at presentation. He was third nerve palsy (4), and a number of retinal vascular
reviewed two weeks later where fluorescein angiography events, such as retinal hemorrhages (5), branch vein
(FA) and gonioscopy were done. FA showed central occlusion (5), and branch retinal artery occlusion (6) have
masking of the retinal vascular bed by extensive retinal been also reported to be associated with Sildenafil use. hemorrhages and gonioscopy was normal. These investigations were repeated after two weeks. The same retinal changes were shown on FA. Gonioscopy revealed neovascularization at the edge of the pupil and This 31-year old man, newly married, had a history of the angle. Panretinal laser photocoagulation was not psychological erectile dysfunction during the first three applied because of extensive retinal hemorrhages so days of his marriage. For that reason, twice the patient retinocryotherapy was given instead. At that time, IOP took oral dose of Viagra, 50 mg, twenty-four hours was still normal. Two weeks later, the angle and the iris before and 48 hours after the onset of the visual neovascularization progressed to involve the whole iris without increase of IOP. Two weeks later, IOP rose to 50 The patient presented with poor vision in the left eye mmHg and the patient treated with antiglaucoma of one-week duration. He is healthy and not known to therapy, topical steroid, and cyclopentolate eye drops. *From the Department of Ophthalmology, King Hussein Medical Center, (KHMC), Amman-Jordan Correspondence should be addressed to Dr. B. Nawaiseh, P.O. Box 925436 Amman 11190 Jordan E-mail: Manuscript received December 31, 2003. Accepted May 27, 2004.
FA at that time showed extensive areas of retinal complete loss of vision in our patient after Sildenafil use capillary non-perfusion and the retinal hemorrhages may be coincidental, but a possible association should decreased significantly so that PRP was given. Over five sessions, one per week, more than 5000 burns were given to the patient. Finally, the visual acuity of his left eye dropped to perception of light and the patient The development of fulminant CRVO in a healthy developed optic atrophy and advanced neovascular young man without any history of systemic illness and glaucoma as a result of fulminant central retinal vein with a history of Sildenafil use hours before onset of occlusion (CRVO). We advised our Patient not to use ocular symptoms may suggest a possible association of Laboratory Investigations
A variety of Investigations had been carried out. Full blood count showed: PCV 44%, ABCs, 7000 micro liter, Laties A, Fraunfelder FT. Ocular safety of Viagra
(Sildenafil citrate). Trans Am Ophthalmol Soc 1999;
platelets 334000 micro liter, ESR 15mm/hour, and CRP was 5mg/dl. Blood film was normal. FBS, Fasting Lipid Pomeranz HD, Smith KH, Hart WM, Egan RA.
profile, KFT, LFT were within normal limit. Serological Sildenafil-associated nonarteritic Ischemic optic studies for vasculitis were negative. Fibrinogen level was neuropathy. Ophthalmology 2002; 109(3): 584-587. 4.0. Thrombosis screen for coagulopathy was negative. Cunningham AV, Smith KH. Anterior ischemic
Serum protein electrophoresis was normal. PT was 13 optic neuropathy associated with Viagra. Journal of Neuro-Ophthalmology 2001; 21:22-25. Donahue SP, Taylor RJ. Pupil-sparing third nerve
palsy associated with Sildenafil citrate (Viagra). Am J Ophthalmol 1998; 126(3): 476-477. Known risk factors for development of CRVO are old Marmor MF, Kessler R. Sildenafil (Viagra) and
age, raised BP, raised IOP, diabetes mellitus, ophthalmology. Sur Ophthalmol 1999; 44: 153-162. hyperlipidemia, chronic lung disease and elevated serum Tripathi AO, Donell NP. Branch retinal artery
IgA levels (7). Inherited thrombophilias are reported to be
occlusion; another complication of Sildenafil. Br J associated with vein occlusions, especially in the young Mc Grath MA, Wechsler F, Hunyor AB, Penny R.
and Middle Ages (8,9). Some studies mentioned that there
Systemic factors contributory to retinal vein was no significant changes observed in mean blood occlusion. Arch Intern Med 1978; 2: 216-220. pressure, IOP and perfusion pressure after Sildenafil Incorvaia C, Bandello F, Parmeggiani F, et al.
treatment when compared to placebo (10). Where as other
Recurrent central retinal vein occlusion in a young studies reported a significant increase in ocular blood thrombophilic patient with factor V Leiden mutation. flow (11). Therefore it wouldn’t be surprising to see an
Euro J Ophthalmol 2002; 12(2): 131-134. increased incidence of vascular ocular bleeds, i.e., Incorvaia C, Lamberti G, Parmeggiani F, et al.
subconjunctival or retinal hemorrhage secondary to Idiopathic central retinal vein occlusion in a sudden rise in ocular blood flow (5). This is probably not
thrompophilic patient with the heterozygous 20210 G/A prothrombin genotype. Am J Ophthalmol 1999; a direct drug effect, but rather secondary to increase in BP and heart rate secondary to sexual arousal (5). Our
Grunwald JE, Siu K, Jacob SS, Dupont J. Effect of
patient may have developed sudden rise in BP as a result Sildenafil citrate (Viagra) on the Ocular circulation. of sexual arousal, which has lead to CRVO. Other Am J Ophthalmol 2001; 131(6): 751-755 cardiovascular events, including myocardial ischemia, Paris G, Sponsel WE, Sandoval SS, et al. Sildenafil
arrhythmia, hypertension, hypotension, and transient increases ocular perfusion. Int Ophthalmol 2001; ischemic attacks, have been also reported after Sildenafil use (12).
Piccoli M, DeSantis LM. Myocardial ischemia after
It is still not clear whether these events are related to administration of Sildenafil: Description of a case and review of the literature. Ital Heart J 2000; 1: 1196- the drug itself or to other factors, such as extensive sexual activity and /or preexisting vascular diseases. Although the occurrence of fulminant CRVO with

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