EyeCon 2025: Jacqueline Theis, OD, FAAO, shares her favorite pearls for managing neurologic disease

Jacqueline (Jaci) Theis, OD, FAAO, from Virginia Neuro-Optometry and the Uniformed Services University School of Medicine, shared a clinically focused lecture on neuro-ophthalmologic emergencies and the role of the retina in early neurologic disease detection at the Optometry Times and Ophthalmology Times EyeCon 2025 conference, September 26 and 27 at the Margaritaville Hollywood Beach Resort in Hollywood, Florida.

She co-presented with Prem Subramanian, MD, PhD, the Clifford R. and Janice N. Merrill Endowed Chair in Ophthalmology at the University of Colorado School of Medicine’s Department of Ophthalmology, guiding attendees through practical insights based on real case experiences.

Theis opened with a central teaching aid she calls the “rule of 3.” As she explained, “if you just have a pupil problem, or you just have an ocular motility problem, or you just have an eyelid problem, the likelihood you have a neuro-ophthalmologic emergency is lower. But if you have 2 of the 3…then the likelihood that someone has a neuro-ophthalmologic emergency is much higher.” This framework helps clinicians quickly triage presentations such as third nerve palsy or Horner’s syndrome, reinforcing the importance of assessing multiple functions whenever one abnormality is noted.

She emphasized careful evaluation in cases of new-onset diplopia. “If you have someone who has new onset double vision and you know that they have a cranial nerve palsy, you need to check the other cranial nerves. So if they have more than one cranial nerve involved, you need to make sure that you send them for neuroimaging and a further workup.”

Another key point centered on visual acuity changes. Theis cautioned against dismissing mild decreases: “Never be surprised by new onset vision loss.” She described a case in which a patient presented with only 20/25 acuity, but confrontation visual fields revealed a bitemporal hemianopsia, ultimately leading to the discovery of a tumor. The reminder was clear: even slight reductions in vision should prompt confrontation fields, pupil testing, and further workup if warranted.

She also touched upon neurodegenerative disease and the retina’s role as an early biomarker. Theis explained that “depending on the disease state, you’re going to have different findings in the retina that can be a biomarker of things that are going on in the body elsewhere.” In Parkinson disease, for instance, dopamine loss affects the amacrine cell layer, leading to reduced contrast sensitivity. Patients may initially complain of night vision difficulties around the time of cataract evaluation. When cataracts do not explain the symptom, Theis advised looking deeper: motility testing, convergence, eyelid function, and blink rate may all provide additional clues.

Similarly, she noted emerging research linking Alzheimer disease to retinal biomarkers of neurodegeneration. This makes retinal imaging an increasingly important adjunct in systemic disease detection.

From a diagnostic technology perspective, Theis underscored the limitations of relying solely on retinal nerve fiber layer (RNFL) OCT. “What I’ve found in my clinic is that the ganglion cell analysis is actually much more sensitive to earlier changes.” She recommended obtaining both RNFL and macular OCT, as early alterations in the ganglion cell layer may be visible before RNFL changes appear.