Altered chromatin topologies caused by balanced chromosomal translocation lead to central iris hypoplasia.

Despite the advent of genomic sequencing, molecular diagnosis remains unsolved in approximately half of patients with Mendelian disorders, largely due to unclarified functions of noncoding regions and the difficulty in identifying complex structural variations. In this study, we map a unique form of central iris hypoplasia in a large family to 6q15-q23.3 and 18p11.31-q12.1 using a genome-wide linkage scan. Long-read sequencing reveals a balanced translocation t(6;18)(q22.31;p11.22) with intergenic breakpoints. By performing Hi-C on induced pluripotent stem cells from a patient, we identify two chromatin topologically associating domains spanning across the breakpoints. These alterations lead the ectopic chromatin interactions between APCDD1 on chromosome 18 and enhancers on chromosome 6, resulting in upregulation of APCDD1. Notably, APCDD1 is specifically localized in the iris of human eyes. Our findings demonstrate that noncoding structural variations can lead to Mendelian diseases by disrupting the 3D genome structure and resulting in altered gene expression.

Near-infrared transillumination imaging combined with aperture photometry for the quantification of melanin in the iris pigment epithelium.

Near-infrared transillumination is used in the diagnosis and the management of different eye diseases. In particular, it enables the visualization of melanin in the pigment epithelium of the iris. This technique is valuable in such conditions as pigment dispersion syndrome and Adie's tonic pupil. Thus, objective quantification of the amount of melanin shedded from the iris pigment epithelium may help in the management of these conditions. By combining aperture photometry with near-infrared iris transillumination this can be achieved. A total of 4 patients (7 eyes) were examined. Three patients were diagnosed with pigment dispersion syndrome in both eyes. One patient had Adie's tonic pupil in one eye. Near-infrared iris transillumination was performed by using a prototype apparatus. Aperture photometry measurements were carried out through specially developed software. The signal-to-noise ratio of the prototype apparatus was 52 dB (399:1). Each pixel within the near-infrared transillumination image corresponded with an area size of the iris of 85 µm x 83 µm. Measurements were taken from several points of the iris in all patients. The average aperture photometry value of transillumination defects was 1321.53 (ADU) ± 501.08 SD, while the average aperture photometry value of the papillary ruff was 90.83 (ADU) ± 53.4. On average transillumination defects transmit 14.55 times more near-infrared light than the papillary ruff. A prototype apparatus for the capture of near-infrared iris transillumination images and custom software enabling aperture photometry measurements of the obtained images has been developed for the purpose of this study. This study demonstrates a potential application of this technique in the diagnosis and management of patients with such conditions as pigment dispersion syndrome and Adie's tonic pupil.

Bilateral asymmetrical partial heterochromia of iris and fundus in Waardenburg syndrome type 2A with a novel MITF gene mutation.

A 3-year-old girl presented with bilateral asymmetrical partial heterochromia of iris and fundus. The parents also complained of bilateral hearing loss in the child. Suspecting an auditory-pigmentary syndrome, systemic and genetic evaluation was performed. The child had profound sensory-neural hearing loss. Targeted gene sequencing revealed a novel nonsense variation in exon 9 of the MITF gene (chr3:70008440A>T) that was pathogenic for Waardenburg syndrome (WS) type 2A. This case highlights the characteristics of the iris and fundus hypochromia, which may provide a clue toward the diagnosis of WS.

Immunohistochemical Characterization of the Ectopic Epithelium Devoid of Goblet Cells From a Posttraumatic Iris Cyst Causing Mucogenic Glaucoma.

PURPOSE: Mucogenic glaucoma is an unusual form of secondary open-angle glaucoma caused by intracameral ectopic mucus-producing epithelium. To date, only 3 cases have been described in detail. Numerous goblet cells in the specimens indicated a possible conjunctival origin. We immunohistochemically characterized the implanted epithelium from an iris cyst responsible for mucogenic glaucoma. METHODS: A series of immunostaining analyses were performed on a sector-iridectomy specimen derived from an eye with mucogenic glaucoma and a history of limbal penetrating injury. An iris cyst was present in the inferonasal quadrant of the right eye of a 58-year-old man. The anterior chamber was filled with hazy, translucent material, and the chamber angle was gonioscopically open. The cyst was resected due to medically uncontrollable high intraocular pressure. RESULTS: The ectopic epithelium was mostly positive for CK19, a corneal and conjunctival epithelial marker. Negative staining for MUC5AC, a secretory mucin, and positive staining for MUC1, a membrane-bound mucin, corroborated the absence of goblet cells. Ectopic epithelial cells were abundantly positive for CK15, a limbal basal cell marker, but there was patchy immunostaining of CK13, a conjunctival epithelial marker, and sparse labeling with CK12, a corneal epithelial marker. Immunostaining patterns of CK15, CK13, and CK12 were nearly mutually exclusive. CONCLUSIONS: The ectopic epithelium of an iris cyst causing mucogenic glaucoma was most likely to originate from limbal basal cells, which showed dual direction of differentiation toward both the conjunctival and corneal epithelia. The membrane-bound mucin may have caused mucogenic glaucoma in the absence of goblet cells.

Role of α1-adrenoceptor subtypes in pupil dilation studied with gene-targeted mice.

PURPOSE: The α1A-adrenoceptor (α1A-AR) subtype was suggested to mediate contraction and trophic effects in the iris dilator muscle, and thus its pharmacological blockade may be involved in intraoperative floppy iris syndrome. We tested the hypothesis that the α1A-AR mediates pupil dilation and trophic effects in the mouse iris. METHODS: The α1-AR subtype mRNA expression was quantified in iris tissue by real-time PCR. To assess the role of individual α1-ARs for mediating pupil dilation, the α1-AR agonist phenylephrine was topically applied to the ocular surface of mice deficient in one of the three α1-AR subtypes (α1A-AR(-/-), α1B-AR(-/-), α1D-AR(-/-), respectively) and wild-type controls. Changes in pupil diameter were measured under a microscope in restrained mice. Moreover, iris and iris muscle thickness were determined in cryosections. RESULTS: Messenger RNA for all three α1-AR subtypes was detected the iris of wild-type mice with a rank order of abundance of α1A ≥ α1B > > α1D. The lack of a single α1-AR gene did not affect mRNA expression of the remaining two receptor subtypes. Phenylephrine induced pupil dilation in wild-type mice that was reduced in extent and duration in α1A-AR(-/-) and, less so, in α1B-AR(-/-) but not in α1D-AR(-/-) mice. The lack of a single α1-AR subtype had no effect on iris or iris muscle thickness. CONCLUSIONS: The α1-AR-induced mydriasis in mice is mediated mainly by the α1A-AR, with a smaller contribution of the α1B-AR, matching the relative abundance of these subtypes at the mRNA level. The lack of a single α1-AR subtype does not appear to cause atrophy in the mouse iris.

Effects of tamsulosin and silodosin on isolated albino and pigmented rabbit iris dilators: possible mechanism of intraoperative floppy-iris syndrome.

PURPOSE: To determine the mechanism of intraoperative floppy-iris syndrome (IFIS) by examining the binding affinity of tamsulosin and silodosin to α-receptors and melanin pigment using control and α(2)-blocker chronically administered in rabbit models. SETTING: Department of Ophthalmology, Kitasato University School of Medicine, Kanagawa, Japan. DESIGN: Experimental study. METHODS: The study was performed in isolated albino and pigmented rabbit iris dilators using pharmacologic and morphologic examinations. RESULTS: For pharmacologic examinations, the mean pK(B) values (pK(B) = -log K(B), where -log K(B) is the equilibrium dissociation constant of the antagonist-receptor complex) of tamsulosin in albino and pigmented rabbits were 9.10 and 8.08 and those of silodosin, 10.3 and 8.11, respectively. The pK(B) values of tamsulosin and silodosin in albino rabbits were significantly higher than in pigmented rabbits. In the isolated rabbit iris dilator, the maximum contraction evoked by 10(-3) mol/L phenylephrine gradually decreased by repetitive application in the chronic α-blocker-administered models. For morphologic examinations, the sizes of the pigment granules of pigment epitheliums for the α-blocker-administered models were irregular. The shape of shared nucleus of dilator muscles and pigment epitheliums changed to lobular, and the dilator muscle layer was thinner than in the control. CONCLUSIONS: The high affinity of α-blockers for α(1)-adrenoreceptors is important in the analysis of the mechanism of IFIS. However, IFIS should not be attributed to long-term binding with receptors alone; the drug-melanin interaction causing dilator muscle atrophy is probably the other important factor in the mechanism of IFIS.

Intraoperative floppy iris syndrome: report of a case and histopathologic analysis.

OBJECTIVE: To understand the role of the α(1A)-adrenoreceptors (ARs) in the pathophysiologic mechanism of intraoperative floppy iris syndrome (IFIS). METHODS: Iris specimens from a patient with tamsulosin hydrochloride-induced IFIS were obtained during trabeculectomy. Specimens underwent histological analysis and immunohistochemical analysis with antibodies specific for actin, myoglobin, α(1A)-ARs, and myosin. Iris specimens from a patient without IFIS were used for comparison. Samples were processed for transmission electron microscopy. RESULTS: Histological examination showed normal dilator muscle, arterioles, stroma, and pigment epithelium. Actin, myosin, and myoglobin distribution and intensities were similar between IFIS and non-IFIS tissue. The staining pattern and colocalization with myosin suggested that α(1A)-ARs are present in iris arteriolar muscularis in addition to the dilator muscle in both IFIS and control irides. Significantly less staining of IFIS tissue was found compared with the non-IFIS iris. Ultrastructures of melanocytes and stroma appeared to be normal. Iris arterioles possessed thick endothelial basement membranes, semilongitudinally oriented muscularis, and abundant perivascular collagen coats. CONCLUSIONS: We confirm the presence of α(1A)-ARs in human iris by results of immunohistochemical analysis. The α(1A)-ARs localize to iris arteriolar muscularis in addition to the iris dilator muscle. This localization suggests that IFIS may develop because of iris vascular dysfunction and that iris vasculature may have structural in addition to nutritive functions.

Impact of liver transplantation on transthyretin-related ocular amyloidosis in Japanese patients.

OBJECTIVE: To evaluate the long-term impact of liver transplantation on ocular manifestations of familial amyloid polyneuropathy (FAP) in Japanese patients. METHODS: Medical records were retrospectively reviewed in a long-term follow-up study. Of 52 patients with FAP amyloidogenic transthyretin Val30Met, 22 patients underwent liver transplantation. We assessed ocular manifestations, including amyloid deposition at the pupillary border, pupillary border with irregularity, vitreous opacities, and glaucoma, in patients who underwent liver transplantation. In addition, we compared the clinical characteristics of vitreous opacities-the most common ocular manifestation of FAP-in patients who underwent liver transplantation and those who did not to determine the effect of transplantation on the progression of ocular amyloidosis. RESULTS: Mean time after FAP onset was 10 years and after liver transplantation was 7 years in patients who underwent liver transplantation. All ocular manifestations increased with time after transplantation. Eight patients (36%) developed vitreous opacities and 4 patients (18%) developed glaucoma during follow-up. Mean time from FAP onset to vitreous opacities onset was significantly shorter in patients with early-onset disease who underwent liver transplantation than in those who did not. CONCLUSIONS: Patients with FAP who undergo liver transplantation continue to have a long-term risk of severe ocular manifestations, especially vitreous opacities and glaucoma, which can restrict their daily lives, even after liver transplantation.

ASCRS White Paper: clinical review of intraoperative floppy-iris syndrome.

Intraoperative floppy-iris syndrome (IFIS) is associated with the use of systemic alpha(1)-antagonists, and tamsulosin in particular. The incidence and severity of IFIS are variable; however, the syndrome is associated with a higher rate of cataract surgical complications, especially when the condition is not recognized or anticipated. Questioning cataract patients preoperatively about current or previous use of alpha(1)-antagonists is therefore important. Intraoperative floppy-iris syndrome surgical management strategies include pharmacologic measures, the use of high-viscosity ophthalmic viscosurgical devices, and mechanical dilating devices. However, sphincterotomies and pupil stretching are ineffective. Whether used alone or in combination, these small-pupil techniques improve the surgical success rate in these cases. Stopping the alpha(1)-antagonist preoperatively is of questionable value.

A study of histopathological features of latanoprost-treated irides with or without darkening compared with non-latanoprost-treated irides.

OBJECTIVES: To study the histopathological features of latanoprost-treated irides with or without darkening, compared with non-latanoprost-treated irides. METHODS: Iridectomy specimens and patient history forms were independently examined by 3 ophthalmic pathologists in a masked fashion. Specimens were evaluated for premalignant changes and for differences in level of pigmentation and degrees of cellularity, inflammation, and vascular abnormalities. RESULTS: The specimens consisted of 22 latanoprost-treated darkened irides, 35 latanoprost-treated irides without darkening, and 35 non-latanoprost-treated irides. There was a statistically significant decrease in the number of nuclear invaginations and prominent nucleoli in latanoprost-treated darkened irides compared with the other 2 groups (P = .004 and P = .005, respectively). The average thickness and pigmentation of the anterior border layer was greater in the latanoprost-treated darkened irides than in the other 2 groups (P = .03 and P = .02, respectively). The latanoprost-treated darkened irides had increased pigmentation of the stroma (P < .001), stromal fibroblasts (P < .001), melanocytes (P = .005), vascular endothelium (P = .02), and adventitia (P < .001) relative to the other 2 groups. CONCLUSIONS: There is no histopathological evidence of premalignant changes in latanoprost-treated darkened irides. The latanoprost-induced iris color changes are due to a thickening of the anterior border layer and an increased amount of melanin in the anterior border layer and within the stromal melanocytes.

Atypical angle closures.

PURPOSE OF REVIEW: Primary angle closure typically causes acute intraocular pressure rise in the phakic elderly. Alternative diagnoses, however, for which iridotomy is usually ineffective, occur commonly in younger, nonhyperopic, and pseudophakic patients. RECENT FINDINGS: High-resolution ultrasonography has advanced our understanding of these entities. Management of platueau iris, present in over half of angle closures with patent iridotomy, may depend on disease stage. Early postoperative pseudophakic patients with myopic shift and narrow angle should be treated with laser capsulotomy for capsular block. Bilateral angle closure is usually due to an offending systemic pharmacologic agent, which must be stopped to resolve the closure. Ciliary body swelling often produces angle closure by blocking the access of aqueous to the anterior chamber, sometimes paradoxically after hypotony. Annular choroidal effusions, difficult to detect without ultrasound, may mimic angle closure. Although cycloplegic and corticosteroid therapy may resolve some entities, pars plana vitrectomy and lensectomy may be necessary to resolve severe ciliary block. We also discuss unique variants of angle closure in patients with retinal disease. SUMMARY: Atypical angle closures should always be considered. Careful examination techniques and new technology can detect the mechanisms involved and direct treatment.

Transgenic mice with ocular overexpression of an adrenomedullin receptor reflect human acute angle-closure glaucoma.

Glaucoma, frequently associated with high IOP (intra-ocular pressure), is a leading cause of blindness, characterized by a loss of retinal ganglion cells and the corresponding optic nerve fibres. In the present study, acutely and transiently elevated IOP, characteristic of acute angle-closure glaucoma in humans, was observed in CLR (calcitonin receptor-like receptor) transgenic mice between 1 and 3 months of age. Expression of CLR under the control of a smooth muscle alpha-actin promoter in these mice augmented signalling of the smooth-muscle-relaxing peptide adrenomedullin in the pupillary sphincter muscle and resulted in pupillary palsy. Elevated IOP was prevented in CLR transgenic mice when mated with hemizygote adrenomedullin-deficient mice with up to 50% lower plasma and organ adrenomedullin concentrations. This indicates that endogenous adrenomedullin of iris ciliary body origin causes pupillary palsy and angle closure in CLR transgenic mice overexpressing adrenomedullin receptors in the pupillary sphincter muscle. In human eyes, immunoreactive adrenomedullin has also been detected in the ciliary body. Furthermore, the CLR and RAMP2 (receptor-activity-modifying protein 2), constituting adrenomedullin receptor heterodimers, were identified in the human pupillary sphincter muscle. Thus, in humans, defective regulation of adrenomedullin action in the pupillary sphincter muscle, provoked in the present study in CLR transgenic mice, may cause acute and chronic atony and, thereby, contribute to the development of angle-closure glaucoma. The CLR transgenic mice used in the present study provide a model for acute angle-closure glaucoma.

Effects of promyelocytic leukemia zinc finger protein on the proliferation of cultured human corneal endothelial cells.

PURPOSE: To determine whether the promyelocytic leukemia zinc finger (PLZF) protein, a transcriptional repressor and negative regulator during cell cycling, plays a role in the proliferation of cultured human corneal endothelial cells (HCECs). METHODS: The expressions of the mRNA and the protein of PLZF were determined by real-time PCR and western blot analysis, respectively. The changes in the expression of the PLZF gene of cultured HCECs were investigated at different times after cell-cell contacts were disrupted by incubation with EDTA. The cell proliferation rate was assessed with a real-time cell electronic sensing (RT-CES) system after cultured HCECs were infected with either PLZF or LacZ encoding adenovirus vector (Ad-PLZF or Ad-LacZ). The PLZF-regulating genes were analyzed by DNA microarray analysis in cultured HCECs infected with Ad-PLZF. RESULTS: The expression of the mRNA of PLZF was first detected when the cultured HCECs became confluent, and the relative amount of PLZF mRNA continued to increase for up to 5 days as the cell-cell contacts were formed more firmly. On the other hand, the expression of the mRNA of PLZF decreased about 20 fold 3 h after EDTA exposure, and gradually returned to the original level as the cell-cell contacts were reformed at 72 h after the exposure. The assessment using the RT-CES system showed that the proliferation of cultured HCECs was inhibited for up to 72 h when infected by Ad-PLZF. DNA microarray analysis revealed that the transforming growth factor-beta stimulated clone 22 (TSC-22) gene was up-regulated by 2.32 fold when infected by Ad-PLZF. CONCLUSIONS: These findings indicate that the expression of PLZF in HCECs is closely related to the formation of cell-cell contacts, and that PLZF may play a role in suppressing their proliferation.

Morphometric effects of long-term exposure to latanoprost.

PURPOSE: To investigate the morphological and melanin granule changes in irides after variable-term exposure to latanoprost, where the latanoprost-induced iris darkening (LIID) side effect has been identified and photographically recorded. DESIGN: Experimental study. PARTICIPANTS: Fifteen LIID cases and 15 untreated controls. METHODS: Iridectomy specimens from LIID cases were collected from patients undergoing trabeculectomy, whereas before surgery they had been on topical latanoprost and there was clear evidence of iris color change from the treating ophthalmologist, which was recorded photographically. A control series of peripheral iridectomies were obtained from blue, heterogeneous, and brown irides. All the specimens were visualized by light and electron microscopy. Masked assessment was made of stromal cell number, cell atypia, anterior border thickness, presence of free stromal melanin, melanin proximity to blood vessels, and change in stromal melanocyte melanin granule numbers and size. For the melanin granule analysis, electron micrographs were subjected to detailed image analysis to quantify the number of melanin granules, size of the granules, and overall percentage filling of the iris stromal melanocytes with melanin. MAIN OUTCOME MEASURES: Iris morphology and melanin granule changes. RESULTS: There was no evident difference in stromal cellularity or anterior border thickness. Atypia, free stromal melanin, and melanin adjacent to blood vessel lumina were identified, but there was no difference between LIIDs and controls. Within stromal melanocytes, we found no change in the total number of melanin granules of the LIID cases, as compared with the brown and heterogeneously colored normals. However, melanin granules in the anterior border melanocytes of the LIID eyes were significantly larger than those in the controls. A trend towards bigger melanin granules was apparent in the deep stroma, but this difference did not reach significance. CONCLUSIONS: In the LIID cases that we examined, the darkening side effect does not seem to be associated with either proliferative or generative iris changes, nor with increases in number of granules. Instead, it appears to be due to small increases in the size of mature melanin granules, particularly in the anterior border region.

Xanthogranuloma of the iris simulating melanoma in an adult.

PURPOSE: To report a case in an adult of xanthogranuloma of the iris that clinically simulated iris melanoma. DESIGN: Observational case report. METHODS: Clinical and histopathologic examination of iris mass obtained from a 77-year-old white woman. RESULTS: High-frequency ultrasonography of the right eye revealed a small, echodense lesion involving the iris root. The mass revealed histopathologic features identical to juvenile xanthogranuloma (JXG), including histiocytes and lymphocytes mixed with multinucleated giant cells, and eosinophilic leukocytes. The histiocytes stained positive for CD68, CD45, and factor XIIIa and negative for S-100 and CD1a. CONCLUSIONS: Xanthogranuloma of the iris can occur in elderly patients. Such lesions should be considered in the differential diagnosis of iris melanoma.