Correspondence

Transient Monocular Blindness Associated with Sexual Intercourse

N Engl J Med 1995; 333:393-394August 10, 1995

Article

To the Editor:

Vasospasm has recently been reconsidered as a possible cause of amaurosis fugax.1-3 Vasospasm was suspected in patients with recurrent episodes of visual loss that could not be attributed to an embolic source, carotid stenosis, hypercoagulability, or vasculitis, and that was not relieved by aspirin, anticoagulation, or steroids. Such patients typically have immediate cessation of amaurotic attacks when treated with the calcium-channel blockers nifedipine or verapamil. Their medical histories often included atherosclerosis, migraine, or ailments related to autoimmunity, suggesting that these factors might precipitate vasoconstriction. We report on a patient with recurrent amaurosis fugax responsive to nifedipine whose history suggests that sexual intercourse was the precipitating mechanism.

A 52-year-old man had experienced 30 episodes of stereotyped visual loss in his right eye during sexual intercourse. On each occasion, just before orgasm, vision in the right eye dimmed over a period of about 30 seconds to complete darkness. Absence of vision persisted for three to five minutes, after which there was gradual return to normal vision over the next two minutes.

The patient had smoked two packs of cigarettes per day for 30 years. He had neither a personal nor a family history of migraine. His only medication was levothyroxine for hypothyroidism. Although he had previously been treated for hypertension, he had not required medication for three years. His resting blood pressure was 130/80 mm Hg. His neurologic examination was normal, and his ophthalmologic examination revealed only minimal arteriovenous crossing changes on direct funduscopy. Magnetic resonance imaging, including angiography, was remarkable only for absence of the A1 portion of the right anterior cerebral artery. The ophthalmic arteries appeared normal and symmetric. The results of a medical evaluation were normal, including electrocardiography, echocardiography, carotid duplex scanning, and blood tests (including a complete blood count; blood chemistry and serologic tests; measurements of the Westergren erythrocyte sedimentation rate, thyroid function, prothrombin time, and partial-thromboplastin time; and tests for antinuclear antibody, protein C, protein S, factor VIII, and rheumatoid factor).

To determine whether amaurosis fugax could be induced by exertion, a treadmill stress test was performed. The patient had no visual symptoms at a maximum heart rate of 178 and blood pressure of 190/85 mm Hg, at which time he became fatigued. The test was discontinued after 50 seconds at stage 4 of the Bruce protocol.

Amaurosis fugax continued to occur during coitus until the patient was instructed to take 20 mg of nifedipine by mouth a half-hour before expected intercourse. subsequently, he has had no episodes of visual loss after taking nifedipine; however, he has had amaurosis fugax when he has not taken nifedipine before intercourse.

Episodes of transient visual loss in the right eye may have occurred when blood was shunted away from the ascending circulation to the perineum, leading to autoregulatory vasoconstriction and retinal hypoperfusion. Vasoconstriction alternatively may be a nonspecific response to elevation in blood pressure during intercourse. This mechanism seems less likely, since neither symptoms nor signs of hypoperfusion occurred with elevated blood pressure during stress testing.

Alan J. Teman, M.D.
University of Miami School of Medicine, Miami, FL 33101

Jacqueline M.S. Winterkorn, Ph.D., M.D.
Douglas Weiner, M.D.
North Shore University Hospital–Cornell University Medical College, Manhasset, NY 11030

3 References

1. 1

   Winterkorn JM, Teman AJ. Recurrent attacks of amaurosis fugax treated with calcium channel blocker. Ann Neurol 1991;30:423-425
   CrossRef | Web of Science | Medline

2. 2

   Burger SK, Saul RF, Selhorst JB, Thurston SE. Transient monocular blindness caused by vasospasm. N Engl J Med 1991;325:870-873
   Full Text | Web of Science | Medline

3. 3

   Winterkorn JMS, Kupersmith MJ, Wirtschafter JD, Forman S. Treatment of vasospastic amaurosis fugax with calcium-channel blockers. N Engl J Med 1993;329:396-398
   Full Text | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Dorothy N Friedberg, Laura E Fox. (1999) Blurred vision during sexual arousal associated with narrow-angle glaucoma. American Journal of Ophthalmology 128:5, 647-648
   CrossRef