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Case Report Outline
A. Background
It is well documented that Anterior Ischemic Optic Neuropathy is caused by infarction of
short posterior cilliary arteries supplying the anterior optic nerve (1,5-8)
The low incidence of this condition 2.3-10.3/100,000 make it difficult to evaluate its true
pathophysiology (2,3)
Possible mechanisms to NAION are:
Insufficiency in the posterior cilliary arteries circulation resulting from critical
perfusion pressure reduction (13)
Ischemic axons in a small crowded scleral canal predispose the disc to an
infarction (13)
B. Case Report
1. History
A 42 y/o Hispanic male comes to our office complaining of blur vision in his r eye for the
past 2 days after the use of Stamina Rx, a natural supplement for erectile
dysfunction. His ocular history denotes a loss of vision in his l eye after the use of
Viagra with same symptoms as in the current episode. Medical history shows
Hypertension, Hypogonadism and inactive Herpes.
2. Examination
Best visual acuity r eye: 20/25, l eye: 20/70
Pupils: round and reactive to light both eyes with sluggish reaction in l eye
c) Confrontation Field: R eye: full field, L eye: inferior defect
d) Ophthalmoscopy shows: R eye with a swollen optic disc with 2 flame shape
hemorrhages and a left eye with a pale optic disc. Retina and macula looks
healthy in both eyes.
e) Anterior Segment: normal both eyes
3. Ancillary Testing
The following test were performed in a 1-4 month period; ESR: normal, VDRL: negative,
Head and Orbit CT scan: normal, HIV: negative, ANA test: normal
Chest X-ray: negative (Sarcoidosis), Visual Field: Inferior defect r eye
constricted field l eye, Head and Orbit MRI: Normal (no plaques), Lumbar
Puncture: normal/negative, Evoked Potential: Negative for conduction and
Congruent for ION
4. Differential Diagnosis
Optic Neuritis
Papillophlebitis
Non-arteritic Ischemic Optic Neuropathy
Arteritic Ischemic Optic Neuropathy
Papilledema
5. Diagnosis
Based on all the labs and studies done, the Evoked Potential test did confirm the
diagnosis of ION and on reviewing the content of Stamina Rx we found an article that
warns consumers about the true content of Stamina Rx which is Tadalafil (Cialis).
C. Conclussion
1. Stamina Rx (tadalafil) was related to the r eye loss of vision of this patient, due to all
the laboratories and studies collected and the fact that the patient experience same
symptomatology and adverse effects as a prior episode of ION in his l eye by the use
of sildenalfil (Viagra).
2. It is important to know that Stamina Rx is only one of six natural supplements
advertise as 100% natural but they actually contain tadalafil.
3. The FDA recommends to stop the use of erectile dysfunction agents (prescribed and
non-prescribed) and to seek medical attention and to discuss increased risk of
NAION in patients who already experienced a NAION in one eye.
D. References
1. Hayreh SS. Erectile dysfunction drugs and non-arteritic ischemic optic neuropathy: is
there a cause and effect relationship? J Neurophthalmol 2005; 25:295-8.
2. Fraunfelder FW . Non-arteritic Anterior Ischemic Optic Neuropathy, Erectile
Dysfunction Drugs, and Amiodarone: Is There a Relationship? J Neurophthalmol
2006; 26:1-3.
3. Dundar SO. Can J Ophthalmol 2007; 42:10-12
4. Fraufelder FW. Visual Side Effects Associated with Erectile Dysfunction Agents. Am J
Ophthalmol 2005;140:723-724.
5. Hayreh SS. Blood supply of the optic nerve head and its role in optic atrophy,
glaucoma and oedema of the optic disc. Br J Ophthalmol 1969; 53:721-48
6. Hayreh SS. The blood supply of the optic nerve head and the evaluation of it: myth
and reality. Prog Retin Eye Res 2001
7. Hayreh SS, Baines JAB. Occlusion of the posterior ciliary artery. III. Effects on the
optic nerve head. Br Ophthalmol 1972;56:754-64
8. Hayreh SS. Anterior ischemic optic neuropathy. I. Terminology and pathogenesis. Br J
Ophthalmol 1974;58:955-63
9. Laties A, Sharpil I. Ocular safety in patients using sildenafil citrate therapy for erectile
dysfunction. J Sex Med 2006;3:12-27.
10. Alert for healthcare professionals: sildenafil citrate (marketed as Viagra). Rockville,
Md: US Food and Drug Administration; July 2005. Available:
http://www.fda.gov/cder/drug/InfoSheets/HCP/sildenafilHCP.htm
11. Viagra. In:Physicians’ Desk Reference, 60th ed. Montvale, NJ:Thomson PDR;
2006:2552-6.
12. Hayreh SS, Podhajsky PA, Zimmerman B. Ipsilateral Recurrence of Nonarteritic
Anterior Ischemic Optic Neuropathy. American Journal of Ophthalmology 2000:
132(5) 734-742.
13. Glaser JS. Neuro-ophthalmology Third Edition Lippincott Williams & Wilkins 1999.
14. Newman NJ, Scherer R. The fellow eye in NAION: report from the ischemic optic
neuropathy decompression trial follow-up study. Am J Ophthalmol 2002
Sep:134(3):317-28.
15. FDA. FDA Public Health Advisory: FDA Warns Consumers Against Taking the
Following Dietary Supplements-Sigra, Stamina Rx and Stamina Rx for Women, Y-Y,
Spontane ES and Uroprin, 2003. Website:
http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01235.html