risk is associated with the presenceof ophthalmoscopically detected non-glaucomatous optic nerve damage.

The Beijing Eye Study is a popula-tion-based study performed in theGreater Beijing area and has beendescribed in detail recently (Wanget al. 2006; Xu et al. 2007). The studyprotocol was approved by the MedicalEthics Committee of Beijing TongrenHospital and all participants gaveinformed consent. Of the 5324 individ-uals aged ‡ 40 years who were invitedto participate in the study, 4439 under-went an eye examination in 2001. Thestudy was repeated in 2006 by re-invit-ing all those who had participated in2001 to undergo a further eye exami-nation. The examinations includedphotography of the macula and opticdisc. The optic disc slides taken in2001 were projected and examined.Non-glaucomatous optic nerve dam-age was defined as decreased, age-related visibility of the retinal nervefibre layer, increased pallor of theneuroretinal rim, decreased diameterof the retinal arteries, and a normallyshaped neuroretinal rim accordingto the inferior-superior-nasal-inferior(ISNT) rule. Non-glaucomatous opticnerve damage was considered only ifan ocular condition, such as a retinalvein occlusion, was not detected as apossible cause of the optic nerve atro-phy. Of the 4439 individuals who par-ticipated in the study in 2001, readableoptic disc photographs were availablefor 4356 (98.1%) subjects. Non-glau-comatous optic neuropathy was foundin 66 eyes (66 ⁄ 8700, 0.8% ± 0.2%,95% confidence interval (CI)0.6)1.0%) in 46 subjects (46 ⁄ 4356,1.1% ± 0.9%, 95% CI 0.8)1.4%).

Of the 4356 subjects, 3208 (73.6%)returned for a follow-up examinationin 2006 (124 [2.8%] subjects haddied and 1024 [23.5%] subjects did notwant to be re-examined or had movedaway). In univariate analysis, mortalityrates were significantly correlated withage (p < 0.001; odds ratio [OR]1.08, 95% CI 1.06)1.10), low familyincome (p < 0.001), level of education(p < 0.001; OR 0.61, 95% CI0.54)0.69), and the presence of non-glaucomatous optic nerve damage(p < 0.001; OR 6.43, 95% CI2.82)14.68). A binary logistic regres-sion analysis, with occurrence of deathas the dependent variable, and age,gender, level of education and presence

of non-glaucomatous optic nerve dam-age as independent variables, revealedthat mortality was still significantlyassociated with age (p < 0.001; OR1.06, 95% CI 1.04)1.08), gender(p < 0.001; OR 0.44, 95% CI0.30)0.66), level of education(p < 0.001; OR 0.64, 95% CI0.56)0.74), and presence of non-glaucomatous optic nerve damage(p = 0.003; OR 3.80, 95% CI1.60)9.09). If family income instead oflevel of education was taken as theindependent parameter in the regres-sion analysis, a similar result wasobtained, with mortality significantlyassociated with age (p < 0.001; OR1.09, 95% CI 1.07)1.11), gender(p < 0.001; OR 0.47, 95% CI0.32)0.69), family income (p < 0.001),and presence of non-glaucomatousoptic nerve damage (p = 0.009; OR3.52, 95% CI 1.37)8.97).

The data suggest that non-glauco-matous optic nerve damage is associ-ated with an increased rate of mortalityin adult Chinese people in GreaterBeijing if no intraocular disorder isdetected as a cause of optic nerve atro-phy. This is paralleled by findings fromthe Blue Mountains Eye Study and theBeaver Dam Study indicating thatglaucoma and retinal vein occlusionsare associated with increased mortalityrates (Lee et al. 2006; Cugati et al.2007). The finding may reflect an asso-ciation between intracranial abnormal-ities and ⁄or systemic diseases andnon-glaucomatous optic nerve damage,and may alert the ophthalmologist toconsider non-glaucomatous optic nervedamage, even if relatively subtle, as afactor potentially associated with anincreased risk for death.

Acknowledgements

This study was supported by the Beij-ing Key Laboratory Fund and theBeijing Natural Science Foundation.

ReferencesCugati S, Wang JJ, Knudtson MD, Rochtchi-

na E, Klein R, Klein BE, Wong TY &

Mitchell P (2007): Retinal vein occlusion

and vascular mortality: pooled data analy-

sis of 2 population-based cohorts. Ophthal-

mology 114: 520–524.

Lee AJ, Wang JJ, Kifley A & Mitchell P (2006):

Open-angle glaucoma and cardiovascular

mortality: the Blue Mountains Eye Study.

Ophthalmology 113: 1069–1076.

Wang Y, Xu L, Zhang L, Yang H, Ma Y &

Jonas JB (2006): Peripapillary atrophy in

elderly Chinese in rural and urban Beijing.

Eye [E-pub ahead of print].

Xu L, Wang Y, Wang S, Wang Y & Jonas

JB (2007): High myopia and glaucoma

susceptibility. The Beijing Eye Study.

Ophthalmology 114: 216–220.

Correspondence:

Professor Liang Xu, Professor Jost B. Jonas

Beijing Institute of Ophthalmology

17 Hougou Street

Chong Wen Men

100005 Beijing

China

Tel: + 49 621 383 2652

Fax: + 49 621 383 3803

Email: Jost.Jonas@augen.ma.uni-heidelberg.

de

Visual field loss after

tadalafil: a case report

Bhaskar Gupta, Sugato Paul,Vikas Sharma and Salim Natha

Department Of Ophthalmology, Royal

Albert Edward Infirmary, Wigan, UK

doi: 10.1111/j.1600-0420.2007.01115.x

Editor,

T he phosphodiesterase-5 (PDE-5)inhibitors sildenafil, tadalafil and

vardenafil are now used widely in thetreatment of erectile dysfunction. Theyhave also recently been reported tohave beneficial effects in the treatmentof idiopathic pulmonary hypertension.We report an unusual case of leftsuperior quadrantanopia within24 hours of ingestion of tadalafil (Cia-lis). A 55-year-old White man, withno previous significant ocular history,reported tunnel vision associated withheadache after taking tadalafil. Visualfield testing after 24 hours and1 month subsequently showed left-sided superior quadrantanopia con-fined by the vertical and horizontalmidlines (Fig. 1). Neurological andsystemic examination and serologicaltesting failed to reveal any cause andthere was no associated risk factor.Limited axial flair and T2W sequences

Acta Ophthalmologica 2008

924

in MRI did not reveal any acuteischaemic event.

Visual adverse events have beenreported after ingestion of sildenafil(Viagra), the anti-impotence drugprescribed to more than 27 millionmen worldwide (Fraunfelder 2005,Lee & Newman 2005). These side-effects include non-arteritic anteriorischaemic optic neuropathy (NAION),an ischaemic infarction of the opticnerve head, which frequently leads tosudden, usually irreversible loss ofvision (Margo & French 2007), andfor which no treatment has yet beenproven effective in terms of eithera cure or recurrence prevention(Wooltorton 2006). Other ophthalmicside-effects reported include compli-cations such as transient changesin colour vision, vision that isdescribed as having a ‘blue tingle’,increased sensitivity to light, conjunc-tival hyperaemia, ocular pain andphotophobia.

Tadalafil is a relatively new drugand few reports on it have been pub-lished. To the best of our knowledge,there has been no previous report ofquadrantanopia following ingestion ofthe drug.

Patients should be warned of thisvery rare but potentially serious andoften irreversible adverse effect.Patients with many vascular risk fac-tors (who may also be more likely tohave erectile dysfunction) may be atgreatest risk. All clinicians, includingophthalmologists, should be moreconsciously aware of this group ofdrugs and their complications than iscurrently the case.

ReferencesFraunfelder FW (2005): Visual side-effects

with erectile dysfunction agents. Am J

Ophthalmol 140: 723–724.

Lee AG & Newman NJ (2005): Erectile dys-

function drugs and non-arteritic anterior

ischaemic optic neuropathy. Am J

Ophthalmol 140: 707–708.

Margo CE & French DD (2007): Ischaemic

optic neuropathy in male veterans pre-

scribed phosphodiesterase-5 inhibitors. Am

J Ophthalmol 143: 538–539.

Wooltorton E (2006): Visual loss with

erectile dysfunction medications. CMAJ

175: 355.

Correspondence:

Bhaskar Gupta MRCOphth

Department of Ophthalmology

Royal Albert Edward Infirmary

Wigan Lane

Wigan WN1 2NN

UK

Tel: + 44 789 134 6906

Fax: + 44 194 282 2251

Email: gupta_bhaskar@yahoo.com

Ischaemic change after

intravitreal bevacizumab

(Avastin�) injection for

macular oedema secondary

to non-ischaemic central

retinal vein occlusion

Kwan Soo Kim, Hae Ran Chang andSujeong Song

Kangbuk Samsung Hospital, Depart-ment of Ophthalmology, Sungkyunkwan

University College of Medicine, Seoul,Korea

doi: 10.1111/j.1755-3768.2008.01175.x

Editor,

A 65-year-old male patient with a12-year history of diabetes pre-

sented with decreased visual acuity inhis right eye of 3 months duration.Best-corrected visual acuity (BCVA)was 0.4 in the right eye (RE) and 1.0in the left eye (LE). A slit-lamp exam-ination showed grade two bilateralnucleosclerosis with no further abnor-malities of the anterior segment.Fundus examination and fluoresceinangiography showed flame-shaped ret-inal haemorrhages in four quadrants

Suprathreshold programme

Suprathreshold programme Left

Defect

Suspect

Suspect

Normal

Normal

24/66

18/66

Right

Defect (log)

1.2

0.8

0.5

Defect (log)

1.2

0.8

0.5

ThresholdSensitivity = 3.3

Fig. 1. Visual field showing left superior quandrantonopia.

The study and data accumulation conformed

to all country laws.

Acta Ophthalmologica 2008

925