Is tadalafil (Cialis) contraindicated in patients with glaucoma, particularly those with a history of narrow-angle glaucoma or other comorbidities such as benign prostatic hyperplasia (BPH)?

Tadalafil and Glaucoma: Contraindications

Tadalafil is contraindicated only in patients at high risk for acute angle-closure glaucoma, but is safe to use in patients with open-angle glaucoma. 1

Critical Distinction Between Glaucoma Types

The key to answering this question lies in distinguishing between the two main types of glaucoma, as they have completely different contraindication profiles for tadalafil:

Open-Angle Glaucoma (Safe)

• Tadalafil is NOT contraindicated in patients with open-angle glaucoma. 1
• Open-angle glaucoma patients can safely use tadalafil without restriction, as the medication does not interfere with aqueous humor dynamics in this condition. 1
• Regular ophthalmologic monitoring should continue as usual (every 12-24 months), but this is for glaucoma management, not because of tadalafil use. 2

Angle-Closure Glaucoma (Contraindicated)

• Tadalafil is contraindicated in patients at high risk for acute angle-closure glaucoma. 1
• The vasodilatory effects of tadalafil could potentially precipitate an acute angle-closure attack in susceptible individuals. 1
• Risk factors for angle-closure glaucoma include Asian ethnicity, older age, hyperopia, and narrow anterior chamber angles. 3, 1

Specific Absolute Contraindication

The only absolute contraindication for tadalafil in the context of eye disease is in patients who have experienced sudden vision loss due to anterior ischemic optic neuropathy after previous PDE5 inhibitor use. 1

Monitoring Recommendations for At-Risk Patients

If prescribing tadalafil to patients with any glaucoma risk factors, implement the following precautions:

• Perform a vision screening exam prior to initiating tadalafil. 4
• Arrange careful follow-up monitoring, particularly for:
  • Patients taking tadalafil long-term at higher doses (due to its 17.5-hour half-life) 1
  • Patients with pre-existing glaucoma risk factors 4
  • Patients at risk of worsening glaucoma 4

Common Clinical Pitfall

Do not confuse the relative caution needed for angle-closure glaucoma with the absolute contraindication for concurrent nitrate use. 1 The nitrate interaction causes life-threatening hypotension and requires a 48-hour washout period, whereas the glaucoma concern is specific to angle-closure type only. 1

Practical Application for BPH Patients

For patients with BPH considering tadalafil 5 mg daily (the approved dose for BPH):

• First, determine the type of glaucoma through gonioscopy. 2
• If open-angle glaucoma: proceed with tadalafil without restriction. 1
• If narrow angles or angle-closure glaucoma: tadalafil is contraindicated. 1
• If no glaucoma but narrow angles on examination: avoid tadalafil due to angle-closure risk. 3, 1