Can an older patient with retinal detachment take Tadalafil (phosphodiesterase inhibitor) 20 mg orally (PO) as needed (PRN) for erectile dysfunction?

Tadalafil Use in Patients with Retinal Detachment

Recommendation

Tadalafil 20mg should not be used in patients with retinal detachment due to the risk of worsening retinal pathology and potential vision loss. 1, 2

Rationale and Evidence

Contraindications and Risks

Phosphodiesterase type 5 inhibitors (PDE5i) like tadalafil have been associated with ocular side effects that are particularly concerning for patients with pre-existing retinal conditions:

• Case reports have documented reversible damage to parafoveal photoreceptors following tadalafil use 1
• Bilateral neurosensory retinal detachment has been reported secondary to tadalafil treatment 2
• The mechanism appears to be related to PDE5 inhibition at the chorioretinal level, which produces:
  • Vasodilation
  • Increased choroidal hydrostatic pressure
  • Exudation into the subretinal space 2

Cardiovascular Considerations

Beyond retinal concerns, PDE5 inhibitors have important cardiovascular considerations:

• The American Heart Association/American College of Cardiology guidelines explicitly warn against concomitant use of PDE5 inhibitors with nitrate medications due to risk of severe hypotension 3
• The Princeton Consensus Panel identifies ED as a substantial independent risk marker for cardiovascular disease 3

Alternative Treatment Options

For patients with retinal detachment requiring treatment for erectile dysfunction, consider:

1. Vacuum constriction devices - A non-pharmacological option that avoids medication-related risks 3

2. Alprostadil (intracavernosal injection or intraurethral suppository) - May be considered if there are no contraindications 3

3. Psychosexual counseling - For patients with predominantly psychogenic ED 3

Important Clinical Considerations

• Patients with retinal detachment should be informed about the potential risks of PDE5 inhibitors on their vision
• A thorough assessment of drug treatment history is crucial in patients with neurosensory retinal detachment 2
• ED is a risk marker for cardiovascular disease, so appropriate cardiovascular evaluation should be considered 3

Monitoring and Follow-up

If a patient with retinal detachment has previously used tadalafil:

• Discontinue the medication immediately
• Arrange ophthalmologic follow-up to monitor for resolution of any retinal changes
• Consider spectral domain OCT to evaluate for hyperreflective changes at the photoreceptor IS-OS interface 1

The evidence clearly shows that the risks of tadalafil use in patients with retinal detachment outweigh the benefits, and alternative treatments for erectile dysfunction should be pursued to protect vision and overall health.