A 76-year-old male presented to the ED for worsening vision and eye pain OS. His history was also remarkable for episodes of weakness and tremors involving RIGHT upper and lower extremities without associated alteration of consciousness for the past few months.

Initial bedside examination notable for corrected distance visual acuities of 20/100 OD and count fingers at 1 foot OS. The RIGHT pupil was 5 mm and briskly reactive to light while the LEFT pupil was 7mm and unreactive to light. Patient’s strength was 5/5 both proximally and distally in the upper and lower extremities. No abnormal movements were noted. 

CT angiogram of the head and neck revealed complete occlusion of the proximal LEFT internal carotid artery and 60-70% stenosis of the proximal RIGHT internal carotid artery. MRI of the brain showed several subacute lacunar infarcts within the periventricular white matter adjacent to the body of the LEFT lateral ventricle, LEFT frontoparietal region, and LEFT subcortical frontal lobe.

Patient was seen in follow up at the neuro-ophthalmology clinic a few weeks later. Corrected distance visual acuities were 20/20 OD and count fingers at 2 feet OS. RIGHT pupil measured 3 mm and was reactive while the LEFT pupil was fixed at 7 mm. Slit lamp examination was most remarkable for severe rubeosis iridis, abnormal blood vessels that grow on the iris surface in response to retinal ischemia.