NeuroOp Guru: PDE-5 inhibitors after NAION — stop or continue?

In this episode of NeuroOp Guru in collaboration with Ophthalmology Times, host Andrew G. Lee, MD, is joined by Drew Carey, MD, to discuss a point-counterpoint article examining whether patients who develop non-arteritic anterior ischemic optic neuropathy (NAION) while using PDE-5 inhibitors should continue taking these medications.¹

Lee is the chair of the Blanton Eye Institute at Houston Methodist Hospital and a professor of ophthalmology, neurology, and neurosurgery at the Weill Cornell Medical College. Carey is the Neil R. Miller Rising Professor of Ophthalmology in the division of neuro-ophthalmology with the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland.

A decades-old association, still without clear answers

The article, written as a point-counterpoint debate between Howard D. Pomeranz, MD, PhD, of Northwell Health, and Ore-Ofe O. Adesina, MD, of UT Health Houston, lays out arguments for and against continued PDE-5 inhibitor use after an NAION event.¹

Carey explained that the suspected mechanism dates to around 2000, when a clinician first noted cases of NAION developing within 24 to 48 hours of PDE-5 inhibitor use—medications that cause vasodilation elsewhere in the body, potentially triggering a steal phenomenon that reduces blood flow to the optic nerve. He noted that a subsequent FDA-mandated prospective study found roughly a twofold increased risk of a first NAION episode among patients using these medications, though he cautioned that establishing direct causation remains difficult given how rare NAION is (about 1 in 12,000 people over age 50) and the conflicting results from larger observational database studies.

Counseling patients on PDE-5 inhibitors

Carey walked through how this evidence shapes counseling across three clinical scenarios: patients on PDE-5 inhibitors who haven not yet had NAION, patients presenting with an acute NAION event, and patients who have already had NAION in one or both eyes.

Any patient presenting with new-onset NAION should be asked about PDE-5 inhibitor use—including over-the-counter or online purchases that may not appear on a medication list—and, increasingly, about GLP-1 receptor agonist use as well. Patients get to weigh the risks themselves, but clinicians need to make sure they understand what those risks are.

For patients who haven not had NAION, Carey said he generally does not raise the medication unless they ask, given how low the baseline risk is—though he will discuss the roughly twofold increase (from about 1 in 12,000 to 1 in 6,000) if a patient brings it up, and support their choice to continue if they judge the benefit worth the risk. For patients in the acute phase of a first NAION event, he advises stopping the medication, since a second ischemic insult during active optic nerve swelling can compound vision loss.

The more difficult conversation comes after recovery: the risk of a same-eye recurrence is low (3% to 5% over five years), but fellow-eye risk is about 20% regardless of risk factors at onset—a figure that could theoretically climb to around 40% if PDE-5 inhibitor use doubles that risk, though this has not been directly studied. Carey said most patients, once presented with that math, choose to stop the medication and explore alternatives with their prescribing physician.

Reference

1. Pomeranz HD, Adesina OO, Lee AG, Van Stavern GP. Should patients who develop nonarteritic anterior ischemic optic neuropathy while using PDE-5 inhibitors continue using these medications? J Neuroophthalmol. 2026;46(2):279-284. doi:10.1097/WNO.0000000000002421