Sildenafil Intoxication Maculopathy: A Hard Diagnosis

describing two cases of maculopathy caused by intoxication by the PDE-5 inhibitor sildenafil.

Retrospective case study based on data from clinical visits including ophthalmic examination, OCT, FAF, FAG/ICG, visual field testing, color vision testing, full-field and multifocal ERG, and EOG.

A 30-year-old and a 27-year-old man presented with sudden bilateral central vision loss and visual symptoms such as photophobia, color vision abnormalities, and pericentral scotoma, after ingestion of excessive doses of sildenafil. In the latter case, the causal role of sildenafil was only identified after pharmacological analysis of supposedly 'herbal' erection pills. BCVA at presentation was 20/16 and 20/20, respectively. On OCT, characteristic thickening and irregular interruption of the EZ, and to a lesser extent the ELM, was seen in both patients. Visual fields showed (peri)central relative scotomas, and full-field ERGs were normal. Color vision was markedly abnormal initially, and multifocal ERG showed disturbed (peri)central responses. BCVA improved in both cases to 20/12.5 and 20/12.5 in the following 6 and 15 months, together with a subjective improvement in visual symptoms. OCT findings gradually improved in both cases, although in the first case there was no complete recovery of the EZ of the perifoveal area on OCT. However the second patient showed restored aspect of the EZ on OCT after 1,5 years.

Sildenafil intoxication maculopathy is a partially reversible condition caused by an overdose of PDE-5 inhibition that affects cone photoreceptor function and structure. Over-the-counter erection pills sold as herbal supplement may contain unlabeled PDE-5 inhibitors.