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coronary blood flow and their role in precipitating sudden coronary death is not certain. It is recommended that use of PDE-5 inhibitors is avoided in men with unstable coronary artery disease, recent myocardial infarction and severe hypotension.

2 Soon after sildenafil became available, there were reports of transient changes in colour vision.1 Blue vision affects approximately 3% of men using sildenafil and does not seem to be a clinically significant problem. There have been no reports of blue vision with vardenafil and tadalafil. More recently, there have been reports of non-arteritic optic ischaemic neuropathy (NAOIN) associated with sildenafil.2 NAOIN has been associated with permanent unilateral or bilateral reduction in visual acuity. Though the mechanism of action is uncertain, it is known that sildenafil cross-reacts with retinal PDE-6. All reported cases were in patients with an adverse cardiovascular risk profile and it may be prudent to avoid sildenafil use in such patients. However, the risk of permanent visual loss is minimal and rare side effects of the newer PDE-5 inhibitors may not yet have come to light.

There have been a number of reports of sudden death in men using sildenafil—despite the precautions outlined above. PDE-5 inhibitors are not associated with changes in

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