To investigate whether retinal arterial narrowing is associated with incident carotid plaque in the general population. Individuals without carotid plaque in 2014 who developed new-onset carotid plaque in 2018 were selected as cases (n = 156) for the atherosclerosis group and matched for age and sex in a ratio of 1:1 for the control group. The effects of the baseline central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and arteriovenous ratio (AVR) on the risk of new-onset carotid plaque were evaluated in multivariable conditional logistic regression models. Subgroup analyses were performed. The mean CRAE, CRVE, and AVR were 153.03 ± 12.77 µm, 232.41 ± 19.78 µm, and 0.66 ± 0.07, respectively. After adjusting for multiple variables, the risk of developing new-onset carotid plaque increased by 4% (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07, p < 0.01) with each 1-µm decrease in CRAE and 80% (OR 1.80, 95% CI 1.17-2.78, p < 0.01) with each 0.1-point decline in AVR. When CRAE and AVR were considered as categorical variables, compared with subjects in the highest CRAE and AVR groups, those in the lowest CRAE and AVR groups had a 159% (OR 2.59, 95% CI 1.34-5.01, p < 0.01) and 93% (OR 1.93, 95% CI 1.08-3.46, p = 0.03) increase in risk of developing new-onset carotid plaque, respectively. However, CRVE was not significantly related to new-onset carotid plaque. Subgroup and interaction analyses were performed, and no significant modification effect was found. In conclusion, retinal arterial narrowing was strongly related to the risk of incident carotid plaque.© 2025 The Author(s). The Journal of Clinical Hypertension published by Wiley Periodicals LLC.