Clinical Phenotype of PDE6B-Associated Retinitis Pigmentosa.

In this retrospective, longitudinal, observational cohort study, we investigated the phenotypic and genotypic features of retinitis pigmentosa associated with variants in the PDE6B gene. Patients underwent clinical examination and genetic testing at a single tertiary referral center, including best-corrected visual acuity (BCVA), kinetic visual field (VF), full-field electroretinography, full-field stimulus threshold, spectral domain optical coherence tomography, and fundus autofluorescence imaging. The genetic testing comprised candidate gene sequencing, inherited retinal disease gene panel sequencing, whole-genome sequencing, and testing for familial variants by Sanger sequencing. Twenty-four patients with mutations in PDE6B from 21 families were included in the study (mean age at the first visit: 32.1 ± 13.5 years). The majority of variants were putative splicing defects (8/23) and missense (7/23) mutations. Seventy-nine percent (38/48) of eyes had no visual acuity impairment at the first visit. Visual acuity impairment was mild in 4% (2/48), moderate in 13% (6/48), and severe in 4% (2/48). BCVA was symmetrical in the right and left eyes. The kinetic VF measurements were highly symmetrical in the right and left eyes, as was the horizontal ellipsoid zone (EZ) width. Regarding the genetic findings, 43% of the PDE6B variants found in our patients were novel. Thus, this study contributed substantially to the PDE6B mutation spectrum. The visual acuity impairment was mild in 83% of eyes, providing a window of opportunity for investigational new drugs. The EZ width was reduced in all patients and was highly symmetric between the eyes, making it a promising outcome measure. We expect these findings to have implications on the design of future PDE6B-related retinitis pigmentosa (RP) clinical trials.

Clinical Phenotype and Course of PDE6A-Associated Retinitis Pigmentosa Disease, Characterized in Preparation for a Gene Supplementation Trial.

Importance: Treatment trials require sound knowledge on the natural course of disease. Objective: To assess clinical features, genetic findings, and genotype-phenotype correlations in patients with retinitis pigmentosa (RP) associated with biallelic sequence variations in the PDE6A gene in preparation for a gene supplementation trial. Design, Setting, and Participants: This prospective, longitudinal, observational cohort study was conducted from January 2001 to December 2019 in a single center (Centre for Ophthalmology of the University of Tübingen, Germany) with patients recruited multinationally from 12 collaborating European tertiary referral centers. Patients with retinitis pigmentosa, sequence variants in PDE6A, and the ability to provide informed consent were included. Exposures: Comprehensive ophthalmological examinations; validation of compound heterozygosity and biallelism by familial segregation analysis, allelic cloning, or assessment of next-generation sequencing-read data, where possible. Main Outcomes and Measures: Genetic findings and clinical features describing the entire cohort and comparing patients harboring the 2 most common disease-causing variants in a homozygous state (c.304C>A;p.(R102S) and c.998 + 1G>A;p.?). Results: Fifty-seven patients (32 female patients [56%]; mean [SD], 40 [14] years) from 44 families were included. All patients completed the study. Thirty patients were homozygous for disease-causing alleles. Twenty-seven patients were heterozygous for 2 different PDE6A variants each. The most frequently observed alleles were c.304C>A;p.(R102S), c.998 + 1G>A;p.?, and c.2053G>A;p.(V685M). The mean (SD) best-corrected visual acuity was 0.43 (0.48) logMAR (Snellen equivalent, 20/50). The median visual field area with object III4e was 660 square degrees (5th and 95th percentiles, 76 and 11 019 square degrees; 25th and 75th percentiles, 255 and 3923 square degrees). Dark-adapted and light-adapted full-field electroretinography showed no responses in 88 of 108 eyes (81.5%). Sixty-nine of 108 eyes (62.9%) showed additional findings on optical coherence tomography imaging (eg, cystoid macular edema or macular atrophy). The variant c.998 + 1G>A;p.? led to a more severe phenotype when compared with the variant c.304C>A;p.(R102S). Conclusions and Relevance: Seventeen of the PDE6A variants found in these patients appeared to be novel. Regarding the clinical findings, disease was highly symmetrical between the right and left eyes and visual impairment was mild or moderate in 90% of patients, providing a window of opportunity for gene therapy.

Genetic architecture of inherited retinal degeneration in Germany: A large cohort study from a single diagnostic center over a 9-year period.

We aimed to unravel the molecular genetic basis of inherited retinal degeneration (IRD) in a comprehensive cohort of patients diagnosed in the largest center for IRD in Germany. A cohort of 2,158 affected patients from 1,785 families diagnosed with IRD was analyzed by targeted next-generation sequencing (NGS). Patients with single-gene disorders (i.e., choroideremia and retinoschisis) were analyzed by Sanger sequencing and multiplex ligation-dependent probe amplification. Our study cohort accounts for ∼7% of the estimated 30,000 patients with IRD in Germany, thereby providing representative data for both the prevalence of IRDs and the mutation spectrum of IRD genes for the population in Germany. We achieved a molecular diagnostic rate of 35-95%, depending on the clinical entities, with a high detection rate for achromatopsia, retinoschisis, and choroideremia, and a low detection rate for central areolar choroidal dystrophy and macular dystrophy. A total of 1,161 distinct variants were identified, including 501 novel variants, reaffirming the known vast genetic heterogeneity of IRD in a mainly outbred European population. This study demonstrates the clinical utility of panel-based NGS in a large and highly heterogeneous cohort from an outbred population and for the first time gives a comprehensive representation of the genetic landscape of IRDs in Germany. The data are valuable and crucial for the scientific community and healthcare providers, but also for the pharmaceutical industry in the progressing field of personalized medicine and gene therapy.

Mutation Detection in Patients with Retinal Dystrophies Using Targeted Next Generation Sequencing.

Retinal dystrophies (RD) constitute a group of blinding diseases that are characterized by clinical variability and pronounced genetic heterogeneity. The different nonsyndromic and syndromic forms of RD can be attributed to mutations in more than 200 genes. Consequently, next generation sequencing (NGS) technologies are among the most promising approaches to identify mutations in RD. We screened a large cohort of patients comprising 89 independent cases and families with various subforms of RD applying different NGS platforms. While mutation screening in 50 cases was performed using a RD gene capture panel, 47 cases were analyzed using whole exome sequencing. One family was analyzed using whole genome sequencing. A detection rate of 61% was achieved including mutations in 34 known and two novel RD genes. A total of 69 distinct mutations were identified, including 39 novel mutations. Notably, genetic findings in several families were not consistent with the initial clinical diagnosis. Clinical reassessment resulted in refinement of the clinical diagnosis in some of these families and confirmed the broad clinical spectrum associated with mutations in RD genes.

Panel-based next generation sequencing as a reliable and efficient technique to detect mutations in unselected patients with retinal dystrophies.

Hereditary retinal dystrophies (RD) constitute a group of blinding diseases that are characterized by clinical variability and pronounced genetic heterogeneity. The different forms of RD can be caused by mutations in >100 genes, including >1600 exons. Consequently, next generation sequencing (NGS) technologies are among the most promising approaches to identify mutations in RD. So far, NGS is not routinely used in gene diagnostics. We developed a diagnostic NGS pipeline to identify mutations in 170 genetically and clinically unselected RD patients. NGS was applied to 105 RD-associated genes. Underrepresented regions were examined by Sanger sequencing. The NGS approach was successfully established using cases with known sequence alterations. Depending on the initial clinical diagnosis, we identified likely causative mutations in 55% of retinitis pigmentosa and 80% of Bardet-Biedl or Usher syndrome cases. Seventy-one novel mutations in 40 genes were newly associated with RD. The genes USH2A, EYS, ABCA4, and RHO were more frequently affected than others. Occasionally, cases carried mutations in more than one RD-associated gene. In addition, we found possible dominant de-novo mutations in cases with sporadic RD, which implies consequences for counseling of patients and families. NGS-based mutation analyses are reliable and cost-efficient approaches in gene diagnostics of genetically heterogeneous diseases like RD.

Visual acuity changes in cone and cone-rod dystrophies.

PURPOSE: The purpose of the study was to evaluate longitudinal visual acuity (VA) changes in cone (CD) and cone-rod dystrophies (CRD) in order to develop recommendations for follow-up strategies and to define an optimal time for potential therapeutic intervention. METHODS: Patients with clinically defined CD and CRD, who had at least three clinical examinations within a follow-up period of a minimum of 2 years, were included in the study. The observation period was divided into segments: between 1-2 visits and 2-3 visits in intervals of 2 years, and between 3-4 visits in 3-year intervals. Disease history was collected during the baseline examination. Median age of onset, age at first examination, and period between disease onset and 1st visit (latency) were estimated. Medians with 25th and 75th quantile of VA decrease in logMAR for each segment of observation were calculated. The median percentage of VA decrease was also calculated. RESULTS: Initial results of the Tuebingen longitudinal study of VA changes in CRD and CD are presented as medians with 25th and 75th quintiles. Twenty-nine patients (14 men and 15 women) were studied. Nineteen of them had CRD and 10 CD. Median age at the baseline visit was 18 (11, 31) years for CRD and 26 (8, 41.5) years for CD. Median age of disease onset was 9 (8, 25) years for CRD and 7.5 (5, 15) years for CD. The median latency was 6.5 (3; 8.25) years in CD and 4 (2, 10) years in CRD patients. VA in CD and CRD patients was significantly different only during the first visit (p < 0.03). VA decrease was highest in the period between 2-3 visits with a median VA decrease of 36%, for CDR and between 3-4 visits for CD with a median VA decrease of 80%. In the CRD group the rate of VA decline was fairly even over the four visits, whereas in the CD group the decline appeared to progressively increase towards the end of the follow-up. CONCLUSION: CRD patients were younger than those with CD at a baseline visit and had a longer period of follow-up. A statistically significant difference in VA in CRD and CD was observed at the first ophthalmological examination only. VA decrease was most prominent in the second decade of life in CRD and in third decade in CD patients. CRD was characterized by a more progressive VA decrease than CD. CRD had a high decline of VA over the second and the third examination, whereas VA decline in CD progressed towards the end of follow-up period (fourth examination). These results should be considered when advising and following up such patients on a long-term basis.

Large deletions of the KCNV2 gene are common in patients with cone dystrophy with supernormal rod response.

Cone dystrophy with supernormal rod response (CDSRR) is considered to be a very rare autosomal recessive retinal disorder. CDSRR is associated with mutations in KCNV2, a gene that encodes a modulatory subunit (Kv8.2) of a voltage-gated potassium channel. In this study, we found that KCNV2 mutations are present in a substantial fraction (2.2-4.3%) of a sample of 367 independent patients with a variety of initial clinical diagnoses of cone malfunction, indicating that CDSRR is underdiagnosed and more common than previously thought. In total, we identified 20 different KCNV2 mutations; 15 of them are novel. A new finding of this study is the substantial proportion of large deletions at the KCNV2 locus that accounts for 15.5% of the mutant alleles in our sample. We determined the breakpoints and size of all five different deletions, which ranged between 10.9 and 236.8 kb. Two deletions encompass the entire KCNV2 gene and one also includes the adjacent VLDLR gene. Furthermore, we investigated N-terminal amino acid substitution mutations for its effect on interaction with Kv2.1 using yeast two-hybrid technology. We found that these mutations dramatically reduce or abolish this interaction suggesting a lack of assembly of heteromeric Kv channels as one underlying pathomechanism of CDSRR.

IQCB1 mutations in patients with leber congenital amaurosis.

PURPOSE: Leber congenital amaurosis (LCA) is genetically heterogeneous, with 15 genes identified thus far, accounting for ∼70% of LCA patients. The aim of the present study was to identify new genetic causes of LCA. METHODS: Homozygosity mapping in >150 LCA patients of worldwide origin was performed with high-density SNP microarrays to identify new disease-causing genes. RESULTS: In three isolated LCA patients, the authors identified large homozygous regions on chromosome 3 encompassing the IQCB1 gene, which has been associated with Senior-Loken syndrome (SLSN), characterized by nephronophthisis and retinal degeneration. Mutation analysis of IQCB1 in these three patients and a subsequent cohort of 222 additional LCA patients identified frameshift and nonsense mutations in 11 patients diagnosed with LCA. On re-inspection of the patient's disease status, seven were found to have developed SLSN, but four maintained the diagnosis of LCA as the kidney function remained normal. CONCLUSIONS: Results show that the onset of renal failure in patients with IQCB1 mutations is highly variable, and that mutations are also found in LCA patients without nephronophthisis, rendering IQCB1 a new gene for LCA. However, these patients are at high risk for developing renal failure, which in early stages is often not recognized and can cause sudden death from fluid and electrolyte imbalance. It is therefore recommended that all LCA patients be screened for IQCB1 mutations, to follow them more closely for kidney disease.

PDZD7 is a modifier of retinal disease and a contributor to digenic Usher syndrome.

Usher syndrome is a genetically heterogeneous recessive disease characterized by hearing loss and retinitis pigmentosa (RP). It frequently presents with unexplained, often intrafamilial, variability of the visual phenotype. Although 9 genes have been linked with Usher syndrome, many patients do not have mutations in any of these genes, suggesting that there are still unidentified genes involved in the syndrome. Here, we have determined that mutations in PDZ domain-containing 7 (PDZD7), which encodes a homolog of proteins mutated in Usher syndrome subtype 1C (USH1C) and USH2D, contribute to Usher syndrome. Mutations in PDZD7 were identified only in patients with mutations in other known Usher genes. In a set of sisters, each with a homozygous mutation in USH2A, a frame-shift mutation in PDZD7 was present in the sister with more severe RP and earlier disease onset. Further, heterozygous PDZD7 mutations were present in patients with truncating mutations in USH2A, G protein-coupled receptor 98 (GPR98; also known as USH2C), and an unidentified locus. We validated the human genotypes using zebrafish, and our findings were consistent with digenic inheritance of PDZD7 and GPR98, and with PDZD7 as a retinal disease modifier in patients with USH2A. Pdzd7 knockdown produced an Usher-like phenotype in zebrafish, exacerbated retinal cell death in combination with ush2a or gpr98, and reduced Gpr98 localization in the region of the photoreceptor connecting cilium. Our data challenge the view of Usher syndrome as a traditional Mendelian disorder and support the reclassification of Usher syndrome as an oligogenic disease.

TRPM1 is mutated in patients with autosomal-recessive complete congenital stationary night blindness.

Night vision requires signaling from rod photoreceptors to adjacent bipolar cells in the retina. Mutations in the genes NYX and GRM6, expressed in ON bipolar cells, lead to a disruption of the ON bipolar cell response. This dysfunction is present in patients with complete X-linked and autosomal-recessive congenital stationary night blindness (CSNB) and can be assessed by standard full-field electroretinography (ERG), showing severely reduced rod b-wave amplitude and slightly altered cone responses. Although many cases of complete CSNB (cCSNB) are caused by mutations in NYX and GRM6, in approximately 60% of the patients the gene defect remains unknown. Animal models of human diseases are a good source for candidate genes, and we noted that a cCSNB phenotype present in homozygous Appaloosa horses is associated with downregulation of TRPM1. TRPM1, belonging to the family of transient receptor potential channels, is expressed in ON bipolar cells and therefore qualifies as an excellent candidate. Indeed, mutation analysis of 38 patients with CSNB identified ten unrelated cCSNB patients with 14 different mutations in this gene. The mutation spectrum comprises missense, splice-site, deletion, and nonsense mutations. We propose that the cCSNB phenotype in these patients is due to the absence of functional TRPM1 in retinal ON bipolar cells.

ABCA4 gene analysis in patients with autosomal recessive cone and cone rod dystrophies.

The ATP-binding cassette (ABC) transporters constitute a family of large membrane proteins, which transport a variety of substrates across membranes. The ABCA4 protein is expressed in photoreceptors and possibly functions as a transporter for N-retinylidene-phosphatidylethanolamine (N-retinylidene-PE), the Schiff base adduct of all-trans-retinal with PE. Mutations in the ABCA4 gene have been initially associated with autosomal recessive Stargardt disease. Subsequent studies have shown that mutations in ABCA4 can also cause a variety of other retinal dystrophies including cone rod dystrophy and retinitis pigmentosa. To determine the prevalence and mutation spectrum of ABCA4 gene mutations in non-Stargardt phenotypes, we have screened 64 unrelated patients with autosomal recessive cone (arCD) and cone rod dystrophy (arCRD) applying the Asper Ophthalmics ABCR400 microarray followed by DNA sequencing of all coding exons of the ABCA4 gene in subjects with single heterozygous mutations. Disease-associated ABCA4 alleles were identified in 20 of 64 patients with arCD or arCRD. In four of 64 patients (6%) only one mutant ABCA4 allele was detected and in 16 patients (25%), mutations on both ABCA4 alleles were identified. Based on these data we estimate a prevalence of 31% for ABCA4 mutations in arCD and arCRD, supporting the concept that the ABCA4 gene is a major locus for various types of degenerative retinal diseases with abnormalities in cone or both cone and rod function.

Using unsupervised learning with variational bayesian mixture of factor analysis to identify patterns of glaucomatous visual field defects.

PURPOSE: To determine whether an unsupervised machine learning classifier can identify patterns of visual field loss in standard visual fields consistent with typical patterns learned by decades of human experience. METHODS: Standard perimetry thresholds for 52 locations plus age from one eye of each of 156 patients with glaucomatous optic neuropathy (GON) and 189 eyes of healthy subjects were clustered with an unsupervised machine classifier, variational Bayesian mixture of factor analysis (vbMFA). RESULTS: The vbMFA formed five distinct clusters. Cluster 5 held 186 of 189 fields from normal eyes plus 46 from eyes with GON. These fields were then judged within normal limits by several traditional methods. Each of the other four clusters could be described by the pattern of loss found within it. Cluster 1 (71 GON + 3 normal optic discs) included early, localized defects. A purely diffuse component was rare. Cluster 2 (26 GON) exhibited primarily deep superior hemifield defects, and cluster 3 (10 GON) held deep inferior hemifield defects only or in combination with lesser superior field defects. Cluster 4 (6 GON) showed deep defects in both hemifields. In other words, visual fields within a given cluster had similar patterns of loss that differed from the predominant pattern found in other clusters. The classifier separated the data based solely on the patterns of loss within the fields, without being guided by the diagnosis, placing 98.4% of the healthy eyes within the same cluster and spreading 70.5% of the eyes with GON across the other four clusters, in good agreement with a glaucoma expert and pattern standard deviation. CONCLUSIONS: Without training-based diagnosis (unsupervised learning), the vbMFA identified four important patterns of field loss in eyes with GON in a manner consistent with years of clinical experience.

Influence of molecular weight on intracameral dextran movement to the posterior segment of the mouse eye.

PURPOSE: Uveoscleral outflow provides a potential pathway to the posterior segment for drug delivery. In this study, the influence of molecular weight on the intraocular distribution of dextran molecules after intracameral injection in the mouse eye was investigated. METHODS: The anterior chambers of the eyes of 64 anesthetized NIH Swiss mice were perfused with various fluorescent dextran solutions (10, 40, 70, and 500 kDa) at 500 nL/min for 10 minutes. At 10, 20, or 60 minutes after the initiation of the anterior chamber perfusion, the mice were killed and tissue obtained for evaluation by fluorescence microscopy. RESULTS: Each of the different molecular weight dextrans were visible in the anterior chamber of the mouse eye after the termination of the experiments. The 10-kDa dextran was observed in the supraciliary space and the supraciliary sclera after 10 minutes and in the anterior sclera after 60 minutes of perfusion. The 40-kDa dextran was detected in the supraciliary space and the anterior sclera after 10 minutes and in the anterior choroid and sclera after 20 and 60 minutes, but not in the posterior segment. The 70-kDa dextran was observed in the supraciliary space and anterior choroid after 10 minutes. After 20 minutes, it was visible in the equatorial choroid. After 60 minutes, it was observed in the posterior choroid. The 500-kDa dextran was observed in the supraciliary space and the anterior choroid after 10 minutes and in the supraciliary sclera at 20 minutes. At 60 minutes, 500-kDa dextran was observed in the equatorial choroid, but not farther toward the posterior. CONCLUSIONS: The influence of molecular weight on the redistribution of macromolecules from the anterior chamber to the posterior globe in the mouse eye appears to be similar to primate eyes. These similarities include passage of all size dextrans through the proximal uveoscleral pathway, the dependence of the extent of posterior movement on the size of the dextran, and the absence of large dextran entry into the distal uveoscleral pathway.

Fourier analysis of scanning laser polarimetry measurements with variable corneal compensation in glaucoma.

PURPOSE: To apply Fourier analysis to the retinal nerve fiber layer (RNFL) thickness measurements obtained with scanning laser polarimetry (SLP), by using variable corneal compensation, and to evaluate the ability of this method to discriminate glaucomatous from normal eyes. METHODS: The study included one eye each of 55 patients with glaucoma and 52 healthy subjects. RNFL thickness measurements were obtained with a modified commercial scanning laser polarimeter (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies, Inc., San Diego, CA) so that corneal birefringence could be corrected on a subject-specific variable basis. The shape of the RNFL thickness double-hump pattern was analyzed by Fourier analysis of polarimetry data. Fourier coefficients and GDx parameters were compared between the two groups. A linear discriminant function was developed to identify and combine the most useful Fourier coefficients to separate the two groups. Receiver operating characteristic (ROC) curves were obtained for each measurement, and sensitivity values (at fixed specificities) were calculated. RESULTS: The Fourier-based linear discriminant function (LDF Fourier) resulted in a sensitivity of 84% for a specificity set at 92%. For similar specificity, the GDx software-provided parameters had sensitivities ranging from 24% to 69%. The area under ROC curve for the LDF Fourier was 0.949, significantly larger than the ROC curve area for the single best GDx software-provided parameter, superior average (0.870). CONCLUSIONS: The combination of Fourier RNFL thickness measures in an LDF, obtained using SLP with variable corneal compensation, improved the ability to discriminate glaucomatous from healthy eyes, compared with the GDx software-provided parameters.

Visual function and perfusion of the optic nerve head after application of centrally acting calcium-channel blockers.

BACKGROUND: In a previous study it was shown that nimodipine 30 mg twice daily leads to an improvement in the visual field in a subgroup of normal-pressure glaucoma patients. To understand the mechanism of action of nimodipine on the visual system, the aim of this study was to examine the influence of nimodipine on different hemodynamic parameters and contrast sensitivity in healthy subjects. METHODS: Thirty-two healthy subjects (21-49 years old, mean age 28 years, 10 male, 22 female) received either nimodipine 30 mg twice a day or a placebo according to the same dosage regimen in a double-blind cross-over study design. The ocular blood flow was measured by means of the ocular blood flow system, the optic nerve head blood flow with the continuous laser Doppler flowmeter (Riva), and contrast sensitivity using the MCT 8000 Multivision Contrast Tester. Measurements were taken at baseline (1T0), 120 min after initial dose (1T3) and after 3 days (3T3) of therapy with 150 mg nimodipine or placebo in total. RESULTS: Contrast sensitivity improved significantly throughout almost all spatial frequencies in the nimodipine-treated subjects ( P=0.01), whereas there was no change in the placebo group. Ocular blood flow and optic nerve head blood flow increased slightly but not significantly in the nimodipine group (1T0: 706.6 microl/min, 9.33 AU; 3T3: 854.3 microl/min, 9.39 AU) and remained unchanged or were even lower in the placebo group ( P>0.05). CONCLUSION: The results showed a significant increase in contrast sensitivity during treatment with nimodipine in healthy subjects. This increase in visual function, however, was not correlated with an increase in ocular or optic nerve head blood flow. Therefore, another mechanism, e.g., a direct effect on the visual system, might be responsible for the improvement in visual function in healthy volunteers under nimodipine therapy.