Is Tadalafil Contraindicated in Glaucoma?
Tadalafil is NOT contraindicated in open-angle glaucoma, but it IS contraindicated in patients at high risk for acute angle-closure glaucoma. The type of glaucoma is critical to this determination.
Key Distinction Between Glaucoma Types
The European Association of Urology guidelines specify that tadalafil is contraindicated only in patients who have experienced sudden vision loss due to anterior ischemic optic neuropathy after previous PDE5 inhibitor use 1. This is the only absolute contraindication related to ocular conditions mentioned in major urology guidelines.
However, acute angle-closure glaucoma represents a specific contraindication that appears in diabetes management guidelines when discussing medications with similar mechanisms, indicating this is a recognized concern for drugs affecting vascular tone 1.
Evidence for Safety in Open-Angle Glaucoma
PDE5 inhibitors do not alter intraocular pressure and are considered safe in patients with established open-angle glaucoma 2.
A 2024 prospective study using optical coherence tomography found no significant changes in posterior ocular structures, including retinal nerve fiber layer thickness, ganglion cell layer, or choroidal parameters, after 1 month of daily 5-mg tadalafil use 3.
The mechanism of action—inhibiting PDE5 to increase cyclic GMP—affects choroidal blood flow and retinal vasculature but does not impair aqueous humor drainage pathways that are already compromised in open-angle glaucoma 2.
Risk Considerations for Angle-Closure Glaucoma
Patients at high risk for acute angle-closure glaucoma should not use tadalafil due to potential vasodilatory effects that could precipitate an acute attack 1. Risk factors include:
- Narrow anterior chamber angles on examination
- Family history of angle-closure glaucoma
- Hyperopia (farsightedness)
- Asian ethnicity
- Older age
Monitoring Recommendations
For patients with open-angle glaucoma using tadalafil:
Vision screening examination prior to initiation is recommended, particularly for patients taking tadalafil long-term at higher doses or those with pre-existing glaucoma risk factors 4.
Careful follow-up monitoring should occur, especially given tadalafil's long half-life of 17.5 hours and prolonged presence in the body 5.
Patients should be counseled to report any sudden vision changes, eye pain, or halos around lights immediately 4.
Clinical Pitfalls to Avoid
The most common error is failing to distinguish between open-angle and angle-closure glaucoma when assessing contraindications 6. While package inserts may list "glaucoma" as a contraindication without specifying type, the clinical evidence supports safety in open-angle glaucoma but caution in angle-closure risk 6.
Do not confuse the absolute contraindication with nitrates (which causes life-threatening hypotension) with the relative caution needed for glaucoma 1, 5. The nitrate interaction is far more dangerous and requires a 48-hour washout period 5.