What oral erectile dysfunction (ED) medication has the least risk of eyesight side effects for a male patient?

Avanafil Has the Lowest Risk of Visual Side Effects Among ED Medications

For patients concerned about eyesight side effects, avanafil is the optimal choice, as it has been specifically shown to cause fewer visual disturbances than other PDE5 inhibitors. 1, 2

Visual Side Effect Profile by Medication

Avanafil: Lowest Visual Disturbance Risk

• Avanafil demonstrates fewer visual disturbances than its competitors, making it the preferred option when eyesight side effects are a primary concern 1
• The drug has improved selectivity for PDE5, which translates to reduced off-target effects on vision 2
• Clinical trials have confirmed avanafil's favorable safety profile with minimal visual complaints 3, 2

Vardenafil: Second-Best Option

• Vardenafil does not inhibit phosphodiesterase-6 (PDE6) to alter color perception, a rare but notable side effect that occurs with sildenafil 4
• This makes vardenafil superior to sildenafil specifically for avoiding visual disturbances 4
• Vardenafil is more selective than sildenafil at inhibiting PDE5, contributing to its better visual side effect profile 5

Sildenafil and Tadalafil: Higher Visual Side Effect Risk

• Sildenafil can cause abnormal color perception due to PDE6 inhibition, though this remains uncommon 4, 5
• Visual disturbances are listed among the common adverse effects of PDE5 inhibitors as a class, with sildenafil being the most frequently implicated 6, 1
• Tadalafil has similar visual side effect risks to sildenafil, though specific comparative data is limited 6

Serious Visual Complications: NAION Risk

Risk Assessment Across All PDE5 Inhibitors

• Non-arteritic anterior ischemic optic neuropathy (NAION) has been reported with all PDE5 inhibitors, though causality remains uncertain 6, 3
• Very-low-quality evidence from 4 million veterans showed PDE5 inhibitors were not associated with increased risk for NAION (absolute risk 4.6 cases per 10,000 men per year; relative risk 1.02) 6
• However, PDE5 inhibitors were associated with increased risk for "possible NAION" (papillitis/optic neuritis; absolute risk 2.4 cases per 10,000 men per year; relative risk 1.34) 6
• This NAION risk appears equivalent across all PDE5 inhibitors—no single agent has been shown safer than others for this rare complication 6

Practical Prescribing Algorithm

First-Line Recommendation

• Prescribe avanafil 50-200 mg as needed for patients prioritizing minimal visual side effects 3, 1
• Avanafil offers the fastest onset of action (effective within 15 minutes) and lowest visual disturbance rates 3, 2

Alternative if Avanafil Unavailable

• Prescribe vardenafil 5-20 mg as needed as the second-best option for avoiding visual side effects 4, 5
• Vardenafil's lack of PDE6 inhibition makes it superior to sildenafil for color vision preservation 4

When to Avoid Sildenafil

• Consider avoiding sildenafil in patients with pre-existing visual concerns or those who work in professions requiring precise color discrimination (pilots, artists, electricians) 4
• If sildenafil is prescribed and visual disturbances occur, switch to avanafil or vardenafil 1, 4

Common Pitfalls to Avoid

• Do not assume all PDE5 inhibitors have identical visual side effect profiles—avanafil and vardenafil are demonstrably better than sildenafil 1, 4
• Do not dismiss patient concerns about visual changes—while rare, these side effects significantly impact quality of life and medication adherence 1
• Do not forget that sexual stimulation is still required for any PDE5 inhibitor to work, regardless of which agent is chosen 3, 7
• Always screen for nitrate use before prescribing any PDE5 inhibitor, as this represents an absolute contraindication 6, 7