A man in his 40s presented at a tertiary emergency center because of a painless vision loss in his right eye that occurred over the previous night. Apart from nicotine use (he smoked 1 pack daily for 20 years), his general and ophthalmologic history was unremarkable.
The patient’s visual acuity was 20/20 OS and hand motions OD, and an ophthalmic examination revealed an afferent pupillary defect, a faint white hue at the level of the choroid, and a retinal nerve fiber layer swelling superior-nasal to the fovea. Indocyanine green angiography results showed a large wedge-shaped area of choroidal ischemia extending from the fovea peripherally (Figure, A). Computed tomography angiography revealed a 1-cm, 90% stenosis of the right internal carotid artery (Figure, B). The patient underwent a carotid endarterectomy the following day, after which his choroidal perfusion improved markedly on indocyanine green angiography follow-up and his visual acuity improved to 20/25 within 2 days.