Reverse flow in ophthalmic artery helps protect the cerebrum from ischemic stroke in total carotid artery occlusion

A 62-year-old male developed ocular ischemic syndrome in his right eye. Carotid angiography and magnetic resonance angiography revealed total occlusion of the right internal carotid artery and a 53% occlusion of the left internal carotid artery. The angiographies also revealed a collateral circulation of a rarely seen reversed blood flow in the right ophthalmic artery, which helped spare the patient from cerebral stroke. Nevertheless, retinal infarction and neovascularization of the iris, retina, and optic disc presented with an unrecoverable visual loss. The balance between treating eye ischemia or cerebral ischemia is a challenge, and timely referral to a neuroradiologist and neurovascular specialist is important to avoid further serious life-threatening complications.