A 75-year-old white man with a 5-month history of bilateral temporal arteritis and subsequent acute vision loss was admitted to the psychiatry service with visual hallucinations, agitation, and aggressive behavior. At the onset of his vision loss, he reported seeing flashing lights. This progressed to complex hallucinations, including dilapidated buildings, construction equipment, and small figures with distinct faces. For the first several months after onset, he identified these images as separate from reality and did not find them disturbing. However, in the 2 weeks before admission, he became increasingly agitated, developing paranoid delusions surrounding the previously benign imagery. He believed the figures were trying to harm him, developed tactile hallucinations of being stabbed with wire, and was convinced that his wife was having affairs with these diminutive men. During his hospital stay, he believed he observed his food being contaminated, and that he was visited nightly by practitioners trying to surgically correct his blindness. The patient had no history of psychiatric illness and endorsed no mood symptoms. A neurologic work-up showed an acute left-frontal infarct on MRI/MRA, likely to have occurred within the past few weeks; however, because of lack of focal deficits and no change from his baseline level of physical functioning, it was deemed an incidental finding. Treatment was initiated with risperidone and rivastigmine.3 After 1 month, the visual hallucinations and delusions had diminished; both were still present to a lesser degree, though the patient was no longer distressed.