An 8-month-old girl with bilateral retinoblastoma, Reese-Ellsworth group VB, International Classification C in the right eye and Reese-Ellsworth group VA, International Classification D in the left eye, presented with total retinal detachment in the left eye. Electroretinogram responses were normal in the right eye and extinguished in the left eye. Initial OAC treatment demonstrated good arterial filling and choroidal blush. A second OAC treatment to the right eye was uneventful, but vasospasm of the left ophthalmic artery was initially noted and resolved with time. Recatheterization in the left eye was successful with good arterial filling and choroidal blush before and after catheterization. Following the second OAC treatment, the family noticed decreased vision and the patient was noted to have no light perception or pupillary responses in either eye. Her right fundus revealed a pale, edematous perifoveal and juxtapapillary retina with “boxcarring” and attenuation of the vessels (Figure 1A). Scattered retinal and subconjunctival hemorrhages were evident in the left eye (Figure 1B), along with purpura on both lower extremities (Figure 2). Neurological evaluation, computed tomography, and magnetic resonance imaging findings were all normal. The family reported a viral prodrome prior to the second OAC treatment. The patient was given sildenafil citrate, steroids, and antihypertensive drops, and over the next week, the retinal vascular tree returned to normal in the right eye (Figure 3A) and the hemorrhages resolved in the left eye (Figure 3B). Retinal and choroidal flow were confirmed with fluorescein angioscopy. Four months later, the child gained fixation and following vision in the left eye, and with resolution of the retinal detachment, the electroretinogram improved to recordable “fair” levels. In the right eye, electroretinogram responses decreased from “very good” to “good.” With local therapy, disease was controlled in both eyes at 6 months' follow-up. Given concerns for an occlusive event, a coagulation workup was performed and, in addition to elevated acute phase reactants, a plasminogen activator inhibitor-1 4G/5G polymorphism was found with elevated plasminogen activator inhibitor levels.