Abstract: Onchocerciasis arises from the transmission of Onchocerca volvulus, a parasitic worm, to humans by the Simulium black fly. Although the primary manifestation of onchocerciasis is dermatological, its most devastating consequences are in the eye. As microfilariae migrate through the eye, the inflammatory response invoked by their death results in the destruction of tissue, and this response, if left unchecked, may lead to severe visual impairment and blindness (“river blindness”). This case illustrates late manifestations of infection with O volvulus in a 21-year-old man who presented with long-standing bilateral vision loss. In doing so, the case should alert physicians to the possibility of onchocerciasis-related vision loss in people from endemic areas, and inform treatment considerations. In such patients, treatment may do little to improve vision but clearly helps eradicate parasitemia, thus preventing other manifestations of onchocerciasis. This case highlights the importance of effective prevention given the poor treatment options for those presenting with advanced eye disease, as well as the potential benefits of treatment in those with early onchocercal eye disease.