[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.159.197.114. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Download PDF
Figure 1.
Structure of the AILPL1 gene with the relative locations of the mutations in the 26 probands.

Structure of the AILPL1 gene with the relative locations of the mutations in the 26 probands.

Figure 2.
W287X/W278X mutation, proband12 at 25 years of age. Posterior pole, right eye, showing atrophic maculararea optic nerve pallor and pigmentary changes.

W287X/W278X mutation, proband12 at 25 years of age. Posterior pole, right eye, showing atrophic maculararea optic nerve pallor and pigmentary changes.

Figure 3.
W287X/W278X mutation, proband8 at 8 years of age. Left eye, early macular changes showing retinal pigmentaryepithelium disruption.

W287X/W278X mutation, proband8 at 8 years of age. Left eye, early macular changes showing retinal pigmentaryepithelium disruption.

Figure 4.
W88X/W88X mutation, proband 2at 30 years of age. Posterior pole, left eye, showing atrophic macular andretinal pigment epithelium disruption and optic nerve pallor.

W88X/W88X mutation, proband 2at 30 years of age. Posterior pole, left eye, showing atrophic macular andretinal pigment epithelium disruption and optic nerve pallor.

Figure 5.
W88X/W88X mutation, proband 2at 30 years of age. Superior midperiphery, left eye, showing intraretinalpigment accumulation, optic nerve pallor, and atrophic macula with pigmentarychanges.

W88X/W88X mutation, proband 2at 30 years of age. Superior midperiphery, left eye, showing intraretinalpigment accumulation, optic nerve pallor, and atrophic macula with pigmentarychanges.

Figure 6.
T114I/P376S mutation, proband20 at 8 years of age. Peripheral retinal mottling.

T114I/P376S mutation, proband20 at 8 years of age. Peripheral retinal mottling.

Figure 7.
T114I/P376S mutation, proband20 at 8 years of age. Right eye, showing macular coloboma-like atrophy andmild optic nerve pallor.

T114I/P376S mutation, proband20 at 8 years of age. Right eye, showing macular coloboma-like atrophy andmild optic nerve pallor.

Figure 8.
Top row, Electroretinogram (ERG),right eye, of the 47-year-old, heterozygous carrier parent of proband 2 carryingthe W88X AIPL1 mutation. It shows a significantly reduced amplitudeof rod-specific scotopic to one third of normal values and of maximal combinedrod and cone response; cone-specific 30-Hz flicker and single flash cone ERGsare within normal limits. Second row, ERG of proband 2 at 27 years of age(carrying the W88X/W88X mutation) showing no measurable responses.Third row, ERG of proband 2's 30-year-old affected sister (carrying the W88X/W88X mutation) showing no measurable responses. Fourth row, Typicalnormal findings in a 45-year-old control.

Top row, Electroretinogram (ERG),right eye, of the 47-year-old, heterozygous carrier parent of proband 2 carryingthe W88X AIPL1 mutation. It shows a significantly reduced amplitudeof rod-specific scotopic to one third of normal values and of maximal combinedrod and cone response; cone-specific 30-Hz flicker and single flash cone ERGsare within normal limits. Second row, ERG of proband 2 at 27 years of age(carrying the W88X/W88X mutation) showing no measurable responses.Third row, ERG of proband 2's 30-year-old affected sister (carrying the W88X/W88X mutation) showing no measurable responses. Fourth row, Typicalnormal findings in a 45-year-old control.

Table 1. 
Clinical and Genetic Characteristics of 26 Probands With AIPL1 Mutations
Clinical and Genetic Characteristics of 26 Probands With AIPL1 Mutations
Table 2. 
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith GUCY2D Mutations vs Patients With AIPL1 Mutations
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith GUCY2D Mutations vs Patients With AIPL1 Mutations
Table 3. 
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith RPE65 Mutations vs Patients With AIPL1 Mutations
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith RPE65 Mutations vs Patients With AIPL1 Mutations
Table 4. 
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith CRX Mutations vs Patients With AIPL1 Mutations
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith CRX Mutations vs Patients With AIPL1 Mutations
Table 5. 
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith CRB1 Mutations vs Patients With AIPL1 Mutations*
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith CRB1 Mutations vs Patients With AIPL1 Mutations*
Table 6. 
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith RPGRIP1 Mutations vs Patients With AIPL1 Mutations
Comparisons of Leber Congenital Amaurosis Phenotypes: PatientsWith RPGRIP1 Mutations vs Patients With AIPL1 Mutations
1.
Leber  T Uber Retinitis pigmentosa und Angeborene Amaurose. Graefes Arch Klin Exp Ophthalmol. 1869;1513- 20
2.
Camuzat  ARozet  JMDollfus  H  et al.  Evidence of genetic heterogeneity of Leber's congenital amaurosis (LCA)and mapping of LCA1 to chromosome 17p13. Hum Genet. 1996;97798- 801
PubMedArticle
3.
Waardenburg  PJ Congenital and early infantile retinal dysfunction (high-graded) amblyopiaand amaurosis of Leber. Waardenburg  PJFranceschetti  AKlein  Deds.Genetics and Ophthalmology. Oxford, England Blackwell Scientific1961;1567- 1581
4.
Heckenlively  JRFoxman  SGParelhoff  ES Retinal dystrophy and macular coloboma. Doc Ophthalmol. 1988;68257- 271
PubMedArticle
5.
Mizuno  KTakei  YSears  ML  et al.  Leber's congenital amaurosis. Am J Ophthalmol. 1977;8332- 42
PubMed
6.
Noble  KGCarr  RE Leber's congenital amaurosis: a retrospective study of 33 cases anda histopathological study of one case. Arch Ophthalmol. 1978;96818- 821
PubMedArticle
7.
Margolis  SScher  BMCarr  RE Macular colobomas in Leber's congenital amaurosis. Am J Ophthalmol. 1977;8327- 31
PubMed
8.
François  J Leber's congenital tapeto-retinal degeneration. Int Ophthalmol Clin. 1968;8929- 947
PubMed
9.
Franceschetti  ADieterle  P L'importance diagnostique de l'electrorétinogramme dans lesdégénérescences tapétorétiniennes avecrétrecissement du champ visuel et héméralopie. Confin Neurol. 1954;14184- 186
PubMedArticle
10.
Elder  MJ Leber congenital amaurosis and its association with keratoconus andkeratoglobus. J Pediatr Ophthalmol Strabismus. 1994;3138- 40
PubMed
11.
Wagner  RSCaputo  ARNelson  LBZanoni  D High hyperopia in Leber's congenital amaurosis. Arch Ophthalmol. 1985;1031507- 1509
PubMedArticle
12.
Stoiber  JMuss  WHRuckhofer  J  et al.  Recurrent keratoconus in a patient with Leber congenital amaurosis. Cornea. 2000;19395- 398
PubMedArticle
13.
Heckenlively  JR Autosomal dominant retinitis pigmentosa. Heckenlively  JRed.Retinitis Pigmentosa. Philadelphia, Pa JB Lippincott Co1988;125- 149
14.
Sorsby  AWilliams  CE Retinal aplasia as a clinical entity. BMJ. 1960;1293- 297Article
15.
Sohocki  MMSullivan  LSMintz-Hittner  HA  et al.  A range of clinical phenotypes associated with mutations in CRX, aphotoreceptor transcription-factor gene. Am J Hum Genet. 1998;631307- 1315
PubMedArticle
16.
Rivolta  CBerson  ELDryja  TP Dominant Leber congenital amaurosis, cone-rod degeneration, and retinitispigmentosa caused by mutant versions of the transcription factor CRX. Hum Mutat. 2001;18488- 498
PubMedArticle
17.
Perrault  IRozet  JMCalvas  P  et al.  Retinal-specific guanylate cyclase gene mutations in Leber's congenitalamaurosis. Nat Genet. 1996;14461- 464
PubMedArticle
18.
Marlhens  FBareil  CGriffoin  JM  et al.  Mutations in RPE65 cause Leber's congenitalamaurosis. Nat Genet. 1997;17139- 141
PubMedArticle
19.
Tzekov  RTLiu  YSohocki  MM  et al.  Autosomal dominant retinal degeneration and bone loss in patients witha 12-bp deletion in the CRX gene. Invest Ophthalmol Vis Sci. 2001;421319- 1327
PubMed
20.
Freund  CLWang  QLChen  S  et al.  De novo mutations in the CRX homeobox geneassociated with Leber congenital amaurosis. Nat Genet. 1998;18311- 312
PubMedArticle
21.
Jacobson  SGCideciyan  AVHuang  Y  et al.  Retinal degenerations with truncation mutations in the cone-rod homeobox(CRX) gene. Invest Ophthalmol Vis Sci. 1998;392417- 2426
PubMed
22.
Silva  EYang  JMLi  Y  et al.  A CRX null mutation is associated with bothLeber congenital amaurosis and a normal ocular phenotype. Invest Ophthalmol Vis Sci. 2000;412076- 1079
PubMed
23.
Lotery  AJJacobson  SGFishman  GA  et al.  Mutations in the CRB1 gene cause Leber congenitalamaurosis. Arch Ophthalmol. 2001;119415- 420
PubMedArticle
24.
den Hollander  AIHeckenlively  JRvan den Born  LI  et al.  Leber congenital amaurosis and retinitis pigmentosa with Coats-likeexudative vasculopathy are associated with mutations in the crumbs homologue1 (CRB1) gene. Am J Hum Genet. 2001;69198- 203
PubMedArticle
25.
Dryja  TPAdams  SMGrimsby  JL  et al.  Null RPGRIP1 alleles in patients with Lebercongenital amaurosis. Am J Hum Genet. 2001;681295- 1298
PubMedArticle
26.
Gerber  SPerrault  IHanein  S  et al.  Complete exon-intron structure of the RPGR-interacting protein (RPGRIP1) gene allows the identification of mutations underlyingLeber congenital amaurosis. Eur J Hum Genet. 2001;9561- 571
PubMedArticle
27.
Sohocki  MMBowne  SJSullivan  LS  et al.  Mutations in a new photoreceptor-pineal gene on 17p cause Leber congenitalamaurosis. Nat Genet. 2000;2479- 83
PubMedArticle
28.
Sohocki  MMPerrault  ILeroy  BP  et al.  Prevalence of AIPL1 mutations in inheritedretinal degenerative disease. Mol Genet Metab. 2000;70142- 150
PubMedArticle
29.
Akey  DTZhu  XDyer  M  et al.  The inherited blindness associated protein AIPL1 interacts with thecell cycle regulator protein NUB1. Hum Mol Genet. 2002;112723- 2733
PubMedArticle
30.
Perrault  IRozet  JMGhazi  I  et al.  Different functional outcome of RetGC1 and RPE65 gene mutations in Leber congenital amaurosis. Am J Hum Genet. 1999;641225- 1228
PubMedArticle
31.
Dharmaraj  SRSilva  ERPina  AL  et al.  Mutational analysis and clinical correlation in Leber congenital amaurosis. Ophthalmic Genet. 2000;21135- 150
PubMedArticle
32.
Lorenz  BGyurus  PPreising  M  et al.  Early-onset severe rod-cone dystrophy in young children with RPE65 mutations. Invest Ophthalmol Vis Sci. 2000;412735- 2742
PubMed
33.
Lotery  AJNamperumalsamy  PJacobson  SG  et al.  Mutation analysis of 3 genes in patients with Leber congenital amaurosis. Arch Ophthalmol. 2000;118538- 543
PubMedArticle
34.
Koenekoop  RKFishman  GAIannaccone  A  et al.  Electroretinographic abnormalities in parents of patients with Lebercongenital amaurosis who have heterozygous GUCY2D mutations. Arch Ophthalmol. 2002;1201325- 1330
PubMedArticle
35.
Marmor  MFZrenner  E Standard for clinical electroretinography (1999 update): InternationalSociety for Clinical Electrophysiology of Vision. Doc Ophthalmol. 1998-1999;97143- 156
PubMedArticle
36.
El-Shanti  HAl-Salem  MEl-Najjar  M  et al.  A nonsense mutation in the retinal specific guanylate cyclase geneis the cause of Leber congenital amaurosis in a large inbred kindred fromJordan [letter]. J Med Genet. 1999;36862- 865
PubMed
37.
Thompson  DAGyurus  PFleischer  LL  et al.  Genetics and phenotypes of RPE65 mutations in inherited retinal degeneration. Invest Ophthalmol Vis Sci. 2000;414293- 4299
PubMed
38.
Hamel  CPGriffoin  JMLasquellec  LBazalgette  CArnaud  B Retinal dystrophies caused by mutations in RPE65: assessment of visualfunctions. Br J Ophthalmol. 2001;85424- 427
PubMedArticle
39.
Koenekoop  RKLoyer  MDembinska  OBeneish  R Visual improvement in Leber congenital amaurosis and the CRX genotype. Ophthalmic Genet. 2002;2349- 59
PubMedArticle
40.
Zhang  QLi  SGuo  X  et al.  Screening for CRX gene mutations in Chinese patients with Leber congenitalamaurosis and mutational phenotype. Ophthalmic Genet. 2001;2289- 96
PubMedArticle
41.
Rivolta  CPeck  NEFulton  ABFishman  GABerson  ELDryja  TP Novel frameshift mutations in CRX associated with Leber congenitalamaurosis. Hum Mutat. 2001;18550- 551
PubMedArticle
42.
Nakamura  MIto  SMiyake  Y Novel de novo mutation in CRX gene in a Japanese patient with Lebercongenital amaurosis. Am J Ophthalmol. 2002;134465- 467
PubMedArticle
43.
Swaroop  AWang  QLWu  W  et al.  Leber congenital amaurosis caused by a homozygous mutation (R90W) inthe homeodomain of the retinal transcription factor CRX: direct evidence forthe involvement of CRX in the development of photoreceptor function. Hum Mol Genet. 1999;8299- 305
PubMedArticle
44.
van Der Spuy  JChapple  JPClark  BJ  et al.  The Leber congenital amaurosis gene product AIPL1 is localized exclusivelyin rod photoreceptors of the adult human retina. Hum Mol Genet. 2002;11823- 831
PubMedArticle
45.
Flanders  MLapointe  MLBrownstein  SLittle  JM Keratoconus and Leber's congenital amaurosis: a clinicopathologicalcorrelation. Can J Ophthalmol. 1984;19310- 314
PubMed
46.
Heher  KLTraboulsi  EIMaumenee  IH The natural history of Leber's congenital amaurosis: age-related findingsin 35 patients. Ophthalmology. 1992;99241- 245
PubMedArticle
47.
Schroeder  RMets  MBMaumenee  IH Leber's congenital amaurosis: retrospective review of 43 cases anda new fundus finding in two cases. Arch Ophthalmol. 1987;105356- 359
PubMedArticle
48.
Leighton  DAHarris  R Retinal aplasia in association with macular coloboma, keratoconus andcataract. Clin Genet. 1973;4270- 274
PubMedArticle
49.
Kennedy  RHBourne  WMDyer  JA A 48-year clinical and epidemiologic study of keratoconus. Am J Ophthalmol. 1986;101267- 273
PubMed
50.
Alström  CHOlson  O Heredo-retinopathia congenitalis monohybrida recessiva autosomalis. Hereditas. 1957;431- 178
51.
Auffarth  GUTetz  MRKrastel  HBlankenagel  AVolcker  HE Complicated cataracts in various forms of retinitis pigmentosa: typeand incidence [in German]. Ophthalmologe. 1997;94642- 646
PubMedArticle
52.
Fishman  GAAnderson  RJLourenco  P Prevalence of posterior subcapsular lens opacities in patients withretinitis pigmentosa. Br J Ophthalmol. 1985;69263- 266
PubMedArticle
Ophthalmic Molecular Genetics
July 2004

The Phenotype of Leber Congenital Amaurosis in Patients With AIPL1 Mutations

Author Affiliations

From the Johns Hopkins Center for Hereditary Eye Diseases, Baltimore,Md (Drs Dharmaraj, De Pool, and Maumenee); the Departments of Molecular Genetics(Drs Leroy, Payne, and Bhattacharya) and Clinical Ophthalmology (Drs Birdand Leroy), Institute of Ophthalmology, University College of London, London,England; the Department of Ophthalmology and Center for Medical Genetics,Ghent University Hospital, Ghent, Belgium (Dr Leroy); the Departments of Ophthalmologyand Pathology, Columbia University, New York, NY (Dr Sohocki); McGill OcularGenetics Lab, Montreal Children's Hospital, Montreal, Quebec (Dr Koenekoop);Unité de Recherches sur les Handicaps Génétiques de l'Enfant,Inserm U393, Hôpital des Enfants Malades, Paris, France (Drs Perraultand Kaplan); the Biomedical and Genetic Engineering Division, Dr AQ Khan ResearchLaboratories, Islamabad, Pakistan (Drs Anwar, Khaliq, and Ismail); StanleyMedical College, University of Madras, Madras, India (Dr Devi); The RetinalFoundation of the Southwest Dallas, Tex (Dr Birch); Instituto de Glaucomay Genetic a Ocular, Rio Piedras, Puerto Rico (Dr Izquierdo); Centre de GénétiqueHumaine Institut de Pathologie et de Génétique, Loverval, Belgium(Dr Van Maldergem); the Department of Biological Sciences, Brunel University,London (Dr Payne); the Electrophysiology Department, Moorfields Eye Hospital,London (Dr Holder). The authors have no relevant financial interest in thisarticle.

Arch Ophthalmol. 2004;122(7):1029-1037. doi:10.1001/archopht.122.7.1029
Abstract

Objectives  To describe the phenotype of Leber congenital amaurosis (LCA) in 26probands with mutations in aryl hydrocarbon receptor interacting protein-like1 protein (AIPL1) and compare it with phenotypesof other LCA-related genes. To describe the electroretinogram (ERG) in heterozygotecarriers.

Methods  Patients with AIPL1-related LCA were identifiedin a cohort of 303 patients with LCA by polymerase chain reaction single-strandconfirmational polymorphism mutation screening and/or direct sequencing. Phenotypiccharacterization included clinical and ERG evaluation. Seven heterozygouscarrier parents also underwent ERG testing.

Results  Seventeen homozygotes and 9 compound heterozygotes were identified.The W278X mutation was most frequent (48% of alleles). Visual acuities rangedfrom light perception to 20/400. Variable retinal appearances, ranging fromnear normal to varying degrees of chorioretinal atrophy and intraretinal pigmentmigration, were noted. Atrophic and/or pigmentary macular changes were presentin 16 (80%) of 20 probands. Keratoconus and cataracts were identified in 5(26%) of 19 patients, all of whom were homozygotes. The ERG of a parent heterozygotecarrier revealed significantly reduced rod function, while ERGs for 6 othercarrier parents were normal.

Conclusions  The phenotype of LCA in patients with AIPL1 mutationsis relatively severe, with a maculopathy in most patients and keratoconusand cataract in a large subset. Rod ERG abnormalities may be present in heterozygouscarriers of AIPL1 mutations.

Clinical Relevance  Understanding and recognizing the phenotype of LCA may help in definingthe course and severity of the disease. Identifying the gene defect is thefirst step in preparation for therapy since molecular diagnosis in LCA willmandate the choice of treatment.

Leber congenital amaurosis (LCA) was first described by Theodore Leberin 18691 as a congenital form of retinitispigmentosa. It represents a clinically and genetically heterogeneous disorderwith severe visual impairment from birth.2,3 Fundusexamination results are not frequently initially normal, but chorioretinalatrophy, narrowing of the retinal vasculature, intraretinal pigment migration,white fundus flecks, and macular aplasia have been described.48 Theretinal basis of the visual loss is shown by absent or severely diminishedrod and cone responses on electroretinography (ERG).9 Nystagmus,enophthalmos, sluggish pupillary responses, keratoconus, cataracts, and hyperopiahave also been described.1012

Leber congenital amaurosis is usually inherited as an autosomal recessivetrait, although dominant inheritance has been reported.1316 Currently,mutations in 6 different retinal genes have been shown to cause LCA. The genesinclude (1) retinal guanylate cyclase (GUCY2D),17 (2) retinal pigment epithelium–specific 65kDprotein (RPE65),18 (3)cone-rod homeobox (CRX),1922 (4)crumbs gene homolog of CRB1,23,24 (5)retinitis pigmentosa GTPase regulator–interacting protein (RPGRIP-1),25,26 and (6) AIPL1, encoding the aryl hydrocarbon receptor interactingprotein-like 1 protein.27,28

The AIPL1 gene consists of 6 exons and encodesa protein of 384 amino acids. This sequence includes 3 tetratricopeptide repeatmotifs thought to be associated with protein-protein interaction, and itssimilarity with aryl hydrocarbon interacting protein is suggestive of a proteinfolding function.27,28 The exactfunctions of the AIPL1 gene are not fully understood.However, recent data suggest that the protein may be involved in photoreceptordifferentiation during development and subsequent survival of photoreceptors.29 Indeed, through interaction with the NUB1 protein,it might be involved in regulation of the cell-cycle progression during photoreceptormaturation.29 Mutations in AIPL1 account for 7% of LCA.28

Clinical outcomes differed for patients with LCA and GUCY2D mutations when compared with those with RPE65 defects3033 interms of the natural history of this disorder. In addition, some heterozygouscarriers of GUCY2D mutations, who have offspringwith LCA, have been shown to have significant cone abnormalities on ERG results,with essentially normal rod ERG findings.34 Mostheterozygotes with RPE65 mutations have normal ERGfindings.32

The purpose of this large study is to describe the phenotype of LCAin patients with AIPL1 mutations and compare it withthe known phenotypes of patients with mutations in other LCA genes. The phenotypeof 26 patients with LCA of different ethnic origins with mutations in AIPL1 is described. The genotype of most patients has previouslybeen published.15,28 The ERG andclinical findings in a female heterozygous carrier are also reported.

METHODS

Informed consent was obtained from all patients involved in this studyor from their legal guardians in accordance with the Declaration of Helsinki.The review and ethics boards of the institutions approved this study.

OPHTHALMIC EVALUATIONS

The clinical diagnosis of LCA was made on the basis of the followingdiagnostic criteria: severe visual impairment from birth or during early infancyaccompanied by nystagmus, absent or very sluggish pupillary responses, andabsent or markedly reduced rod and cone ERGs. All ERGs were performed accordingto the International Society for Clinical Electrophysiology of Vision standards.35 The examinations were undertaken in 5 centers andincluded slitlamp biomicroscopy, retinoscopy, and indirect ophthalmoscopyfollowing pupillary dilation (Table 1).Clinical pictures were taken, and keratometry was performed.

GENETIC EVALUATIONS

DNA was extracted from peripheral blood leukocytes or cheek swabs. Acohort of 303 patients with LCA was screened for mutations in AIPL1. Patients were from a wide range of racial and ethnic backgrounds.The 6 exons of AIPL1 were screened using single-strandconformation polymorphism analysis (SSCP) followed by direct sequencing whenan aberrant migration pattern was noted on the SSCP gels. In 39 probands,direct sequencing was used to screen for mutations in AIPL1, while in the others, SSCP was initially undertaken using primersand conditions previously described.27 Thegenotype of most of the patients with AIPL1-relatedLCA in this study has been published previously (Figure 1).27,28

RESULTS

Mutations in AIPL1 were detected in 26 probandswith LCA (Figure 1). Seventeen probandswere homozygotes, while 9 were compound heterozygotes. Twenty-four of the52 mutated AIPL1 alleles carried the W278X mutation.All sequence changes identified in our patients were absent in 205 controlsamples.

NIGHT BLINDNESS, PHOTOATTRACTION, AND PHOTOAVERSION

Night blindness was reported in 13 probands and photoaversion in 4.Photoattraction (staring at lights) was noted in 2 probands (Table 1).

VISUAL ACUITIES AND CYCLOPLEGIC REFRACTIONS

Visual acuities were found to vary between probands and ranged from20/400 to light perception. Nine patients had light perception. Seven patientshad hand motion vision (Table 1).Cycloplegic refractions performed in 10 patients showed hyperopia in 8 (+3.00diopters [D] to +7.00 D) and myopia in 2 (–0.50 D to –2.75 D).

RETINAL AND MACULAR APPEARANCE

Twenty-four probands with an AIPL1-relatedLCA genotype had some form of pigmentary retinopathy that ranged from mildmidperipheral salt and pepper-like retinopathy to diffuse and severe chorioretinopathy(Figure 2, Figure 3, Figure 4, Figure 5, Figure 6 and Figure 7).The youngest patient with pigmentary changes was 4 months old. Two patients,a 2-year-old and a 3-year-old, had essentially normal retinas with indistinctfoveal reflexes. A maculopathy of variable appearance was noted in a significantnumber of patients (Figure 2, Figure 3, Figure 4, Figure 5, and Figure 7). Information about the macularappearance was available in 20 of the 26 probands. Maculopathy was noted in16 (80%) of 20 probands. In 4 probands, all young children (ranging from ages2-6 years), an abnormal indistinct foveal reflex was noted, which likely representsan early stage of maculopathy. This strongly suggests that a significant numberof patients with LCA and AIPL1 mutations developa maculopathy. The maculopathy ranged in appearance from mild foveal atrophywith variable degrees of macular stippling to aplasia. The youngest patientwith macular atrophy was 8 years old (Table1).

KERATOCONUS AND CATARACTS

Information about the presence of keratoconus was available in 19 probands(Table 1). Keratoconus was diagnosedin 6 probands (32%), and cataracts were noted in association with the keratoconusin 5 of these 6 patients. Distinct hydrops with scarring and breaks in theDescemet membrane were noted in proband 17. The cataracts ranged from corticalchanges to posterior subcapsular cataracts. Of interest, keratoconus and cataractswere only seen in patients who were homozygous for AIPL1 mutations. Keratoconus was not observed in patients with compoundheterozygous mutations. The youngest patient with keratoconus and cataractwas aged 10 years.

OPTIC DISC APPEARANCE

Varying degrees of optic nerve pallor were noted in all patients afterthe age of 6 years. The optic nerve head appeared normal in children youngerthan 6 years, except in an infant (Table1).

ERG FINDINGS

The ERG findings obtained in the 3 sets of clinically normal parentsof probands 7, 10, and 26 who carry the AIPL1 mutationin a heterozygous state did not show any abnormalities. However, the ERG of1 carrier parent of proband 2 with the W88X mutation showed significant rodabnormalities (Figure 8). She didnot have any ocular complaints, and her clinical examination findings werenormal. This 47-year-old mother had vision of 20/20 OU. Although her retinalexamination results were unremarkable, full-field flash ERG showed rod b-waveamplitudes to be reduced to approximately one third of normal, with no changein implicit time. This is well below the lower limit of normal. The 30-Hzflicker and single flash cone responses were within normal limits (Figure 8). The ERG responses were reproducibleon repetition.

COMPARING THE LCA PHENOTYPES

The LCA phenotypes with mutations in the other LCA genes (GUCY2D, RPE65, CRX, CRB1, and RPGRIP1) were comparedwith the LCA phenotypes of the current study and tabulated in Table 2, Table 3, Table 4, Table 5, and Table 6.The AIPL1-related LCA phenotype is severe in nature,with pronounced macular involvement in individuals older than 6 years withvarying degrees of optic nerve pallor. Additional findings of keratoconusand cataract could be present.

Both GUCY2D-related and AIPL1-related LCA phenotypes have markedly decreased visual acuities,visual fields, and ERGs.30,31,33 However,maculopathy, remarkable peripheral pigmentary changes, cataract, and significantoptic disc pallor were not detected in patients with mutations in GUCY2D.30,31,33 Keratoconuswas reported by El-Shanti et al36 in a Jordanianpedigree. Compared with the reported GUCY2D phenotype,30,31,33 theAIPL1 phenotype appears to be similar in severity of visual loss. Phenotypicaldifferences exist in the pattern of pigmentary changes, cataract, and keratoconus,which are more frequent in AIPL1-related LCA (Table 2).

The RPE65 phenotype reported in earlier studies3032,37,38 showsthat the visual acuities, visual fields, and ERG measurements were betterthan in the AIPL1 phenotype. Patients with RPE65-relatedLCA may develop a mild maculopathy, and the documented peripheral retinalchanges are characterized as grainy and/or salt and pepper-like. The maculopathyof patients with AIPL1-related LCA appears to bemore pronounced in all probands older than 6 years, while the peripheral retinalchanges range from mottling to bone spicule-like formation. Cataract and keratocunuswere present in one third of the patients with AIPL1-relatedLCA. Lorenz et al32 conclude that patientswith LCA and RPE65 mutations are distinguishableon clinical grounds, based on their measurable visual acuities, their transientvisual improvement in childhood followed by deterioration in later life, measurablecone ERGs (which also diminish in later life), measurable visual fields, andsignificant night blindness. The data from our study suggest that patientswith LCA and mutations in AIPL1 do not have a similarcourse (Table 3).

From the several reported cases of patients with LCA and CRX mutations, visual acuities of 20/300 to light perception, with1 case of 20/80, were described.15,16,1922,31,33,3943 Markedatrophy in the macula was recorded in 71% of CRX-relatedLCA, while in AIPL1-related LCA, maculopathy waspronounced in 80% of the patients after 6 years of age. Marked pigmentaryretinopathy was noticed in 84% of patients with AIPL1-relatedLCA unlike in CRX-related LCA, where it was observedin 33% (Table 4).

Compared with that of patients with CRB1 mutations,the phenotype of our patients with AIPL1 mutationsappears to be less variable and more severe. Small white dots and zonal retinal/choroidalhypoplasia were seen in the patients with CRB1-relatedLCA23 but not in patients with AIPL1-related LCA (Table 5).The presence of cataract, keratoconus, and optic disc pallor were not reportedin the CRB1-related LCA phenotype. The constant featuresreported in the CRB1-related phenotype were moderateto high hyperopia, the relatively early appearance of white spots, and nummularpigment clumps in the retina.23

The RPGRIP1-related LCA phenotype has beenreported in 3 patients.25 Visual acuity waslight perception. Hyperopia and absence of intraretinal pigment migrationwere noted in 2 patients. However, bone spicule-like pigmentary deposits inthe midperipheral zone were noted in a third patient. No evidence of maculopathyas seen in the patients with AIPL1-related LCA wasobserved (Table 6).

COMMENT

The retinal phenotype of AIPL1-related LCAis that of a severe, congenital retinal dystrophy with a notable maculopathy.The retinal appearances in our patients ranged from near normal (in a 3-year-oldand a 6-year-old) to severely atrophic (and in all patients older than 6 years)with marked maculopathy and pigmentary retinopathy. Varying degrees of intraretinalpigment migration culminating in bone spicule-like pigment and gross pigmentclumps in the retinas were observed. Overall, a high prevalence of macularlesions was observed in our patients compared with patients with LCA causedby mutations in the other 5 genes implicated in this disease. Atrophic macularlesions were particularly frequent and were observed in 16 (80%) of 20 patients;11 harbored a premature stop-codon mutation, either in a homozygous or a heterozygousstate. Macular involvement as seen on ophthalmoscopy likely begins with anindistinct dull or irregular foveal reflex and progresses to a diffuse ill-definedarea of retinal pigment stippling and atrophy, leading to a marked atrophicmaculopathy. Owing to the differences in age at the time of first examination,it was not possible to determine the accurate age of onset of the maculopathy.

The heterozygous carrier parent of the W88X mutation was found to havea significant and reproducible rod ERG abnormality with essentially normalcone ERG results. These ERG findings are significantly different from theheterozygous carriers of GUCY2D mutations, who havesignificant cone ERG abnormalities but relatively normal rod ERG findings.34 The rod ERG abnormalities in the AIPL1 carrier correlate with recent reports showing AIPL1 expression exclusively in rod photoreceptors in the differentiatedretina.44 However, more ERGs in carriers of AIPL1 mutations need to be studied to better understandthe role of AIPL1 in relation to rod function.

The presence of keratoconus in patients with LCA has been well documented.4548 Thehigh incidence of keratoconus in patients with a homozygous sequence changeof AIPL1 in our cohort may well be significant. Keratoconuswas observed in 6 probands, all with homozygous mutations. There is no definitiveconsensus about the origin of keratoconus in patients with LCA. The incidenceof keratoconus has been reported to be as high as 54.5 cases per 100.0 inthe general population, and it has been noted in 29% of children with LCAand 2% of all children with blindness.10,49 Keratoconusin patients with LCA occurred in 2% of 0- to 14-year-olds and in 30% of 15-to 45-year-olds, further illustrating the later onset of the pathologic cornealfeatures in comparison with the retinal dysplasia.50 Theabsence of keratoconus prior to 9 years of age also has been well documented46 and is the case in our cohort too.

Cataract has been associated with many different types of retinal dystrophy.Its association with retinitis pigmentosa has been well documented.51,52 Cataract has been noted at or beyondthe second decade of life in patients with LCA.46 Inthis study, cataracts were observed in 5 probands (27%). Progressive retinaldegenerative changes in association with keratoconus and cataract have beenreported during the course of the disorder.46,47 Theincidence of both keratoconus and cataract increased with increasing age inour cohort.

The LCA phenotypes are highly variable15,23,31,32 andchange with age,46 and the phenotypes associatedwith the currently known LCA genes overlap.3133 Comparisonsbetween the reported LCA phenotypes of different studies23,25,3033 arehampered by a lack of uniform assessment strategies, age matching, and uniformfollow-up. Despite these obvious difficulties, it is important to study theseLCA phenotypes in an effort to understand the evolution of disease based ongenotype.

In summary, patients with AIPL1-related LCAappear to have a particularly severe phenotype, characterized by marked visualimpairment, nondetectable fields and ERGs, optic disc pallor, maculopathy,peripheral retinal bone spicule-like pigmentation, and a significant prevalenceof keratoconus and cataract.

Mutations in AIPL1 disrupt the normal functionof photoreceptors. AIPL1 is not only expressed inmature rod photoreceptors44 but also duringdevelopment in both rods and cones.29 The dysfunctionalrole of AIPL1 in photoreceptor cell cycle progressionleads to photoreceptor cell death during development by disrupting the normalregulation of the cell cycle.29 More detailedunderstanding of the pathogenesis of each molecular subtype of LCA will providefurther insight into treatment.

Back to top
Article Information

Correspondence: Sharola Dharmaraj, MD, FRCS, The Johns Hopkins Centerfor Hereditary Eye Diseases, Maumenee 517, Wilmer Eye Institute, Johns HopkinsMedical Institutions, 600 N Wolfe St, Baltimore, MD 21287-9237 (sdharmaraj@jhmi.edu).

Submitted for publication October 10, 2002; final revision receivedApril 3, 2003; accepted June 6, 2003.

This research was supported by grants from the Foundation for RetinalResearch, Highland Park, Ill; the Edel & Krieble Funds of the Johns HopkinsCenter for Hereditary Eye Diseases, Baltimore, Md; the Grousbeck Family Foundation,Stanford, Calif; the Fonds voor Research in Oftalmologie/Fonds de la Rechercheen Ophtalmologie, Edegem, Antwerp, Belgium (Dr Leroy); the Bijzonder Onderzoeksfondsof Ghent University, Ghent, Belgium (Dr Leroy); the Foundation Fighting Blindness-Canada,Toronto, Ontario (Dr Koenenkoop); the Canadian Institutes of Health Research,Ottawa, Ontario (Dr Koenenkoop); Fonds de la recherche en Santé duQuébéc, Montréal, Québéc (Dr Koenenkoop);the Kirchgessner Foundation, Los Angeles, Calif (Dr Sohocki); the KnightsTemplar Eye Foundation, Chicago, Ill (Dr Sohocki); the Foundation FightingBlindness, Owings Mills, Md (Dr Sohocki); Fight for Sight, New York (Dr Sohocki);the Research Division of Prevent Blindness America, Schaumburg, Ill (Dr Sohocki);and William R. Acquavella (Dr Sohocki).

Dr Sohocki is the William R. Acquavella Scholar of Ophthalmic Research,Columbia University, New York.

These authors contributed equally to the study: Sharola Dharmaraj, MD,FRCS, and Bart P. Leroy, MD.

We thank the families for support and cooperation. We also thank thephotography departments of all the institutes for their professional assistanceand to Olof Sundin, PhD, for reviewing the manuscript.

References
1.
Leber  T Uber Retinitis pigmentosa und Angeborene Amaurose. Graefes Arch Klin Exp Ophthalmol. 1869;1513- 20
2.
Camuzat  ARozet  JMDollfus  H  et al.  Evidence of genetic heterogeneity of Leber's congenital amaurosis (LCA)and mapping of LCA1 to chromosome 17p13. Hum Genet. 1996;97798- 801
PubMedArticle
3.
Waardenburg  PJ Congenital and early infantile retinal dysfunction (high-graded) amblyopiaand amaurosis of Leber. Waardenburg  PJFranceschetti  AKlein  Deds.Genetics and Ophthalmology. Oxford, England Blackwell Scientific1961;1567- 1581
4.
Heckenlively  JRFoxman  SGParelhoff  ES Retinal dystrophy and macular coloboma. Doc Ophthalmol. 1988;68257- 271
PubMedArticle
5.
Mizuno  KTakei  YSears  ML  et al.  Leber's congenital amaurosis. Am J Ophthalmol. 1977;8332- 42
PubMed
6.
Noble  KGCarr  RE Leber's congenital amaurosis: a retrospective study of 33 cases anda histopathological study of one case. Arch Ophthalmol. 1978;96818- 821
PubMedArticle
7.
Margolis  SScher  BMCarr  RE Macular colobomas in Leber's congenital amaurosis. Am J Ophthalmol. 1977;8327- 31
PubMed
8.
François  J Leber's congenital tapeto-retinal degeneration. Int Ophthalmol Clin. 1968;8929- 947
PubMed
9.
Franceschetti  ADieterle  P L'importance diagnostique de l'electrorétinogramme dans lesdégénérescences tapétorétiniennes avecrétrecissement du champ visuel et héméralopie. Confin Neurol. 1954;14184- 186
PubMedArticle
10.
Elder  MJ Leber congenital amaurosis and its association with keratoconus andkeratoglobus. J Pediatr Ophthalmol Strabismus. 1994;3138- 40
PubMed
11.
Wagner  RSCaputo  ARNelson  LBZanoni  D High hyperopia in Leber's congenital amaurosis. Arch Ophthalmol. 1985;1031507- 1509
PubMedArticle
12.
Stoiber  JMuss  WHRuckhofer  J  et al.  Recurrent keratoconus in a patient with Leber congenital amaurosis. Cornea. 2000;19395- 398
PubMedArticle
13.
Heckenlively  JR Autosomal dominant retinitis pigmentosa. Heckenlively  JRed.Retinitis Pigmentosa. Philadelphia, Pa JB Lippincott Co1988;125- 149
14.
Sorsby  AWilliams  CE Retinal aplasia as a clinical entity. BMJ. 1960;1293- 297Article
15.
Sohocki  MMSullivan  LSMintz-Hittner  HA  et al.  A range of clinical phenotypes associated with mutations in CRX, aphotoreceptor transcription-factor gene. Am J Hum Genet. 1998;631307- 1315
PubMedArticle
16.
Rivolta  CBerson  ELDryja  TP Dominant Leber congenital amaurosis, cone-rod degeneration, and retinitispigmentosa caused by mutant versions of the transcription factor CRX. Hum Mutat. 2001;18488- 498
PubMedArticle
17.
Perrault  IRozet  JMCalvas  P  et al.  Retinal-specific guanylate cyclase gene mutations in Leber's congenitalamaurosis. Nat Genet. 1996;14461- 464
PubMedArticle
18.
Marlhens  FBareil  CGriffoin  JM  et al.  Mutations in RPE65 cause Leber's congenitalamaurosis. Nat Genet. 1997;17139- 141
PubMedArticle
19.
Tzekov  RTLiu  YSohocki  MM  et al.  Autosomal dominant retinal degeneration and bone loss in patients witha 12-bp deletion in the CRX gene. Invest Ophthalmol Vis Sci. 2001;421319- 1327
PubMed
20.
Freund  CLWang  QLChen  S  et al.  De novo mutations in the CRX homeobox geneassociated with Leber congenital amaurosis. Nat Genet. 1998;18311- 312
PubMedArticle
21.
Jacobson  SGCideciyan  AVHuang  Y  et al.  Retinal degenerations with truncation mutations in the cone-rod homeobox(CRX) gene. Invest Ophthalmol Vis Sci. 1998;392417- 2426
PubMed
22.
Silva  EYang  JMLi  Y  et al.  A CRX null mutation is associated with bothLeber congenital amaurosis and a normal ocular phenotype. Invest Ophthalmol Vis Sci. 2000;412076- 1079
PubMed
23.
Lotery  AJJacobson  SGFishman  GA  et al.  Mutations in the CRB1 gene cause Leber congenitalamaurosis. Arch Ophthalmol. 2001;119415- 420
PubMedArticle
24.
den Hollander  AIHeckenlively  JRvan den Born  LI  et al.  Leber congenital amaurosis and retinitis pigmentosa with Coats-likeexudative vasculopathy are associated with mutations in the crumbs homologue1 (CRB1) gene. Am J Hum Genet. 2001;69198- 203
PubMedArticle
25.
Dryja  TPAdams  SMGrimsby  JL  et al.  Null RPGRIP1 alleles in patients with Lebercongenital amaurosis. Am J Hum Genet. 2001;681295- 1298
PubMedArticle
26.
Gerber  SPerrault  IHanein  S  et al.  Complete exon-intron structure of the RPGR-interacting protein (RPGRIP1) gene allows the identification of mutations underlyingLeber congenital amaurosis. Eur J Hum Genet. 2001;9561- 571
PubMedArticle
27.
Sohocki  MMBowne  SJSullivan  LS  et al.  Mutations in a new photoreceptor-pineal gene on 17p cause Leber congenitalamaurosis. Nat Genet. 2000;2479- 83
PubMedArticle
28.
Sohocki  MMPerrault  ILeroy  BP  et al.  Prevalence of AIPL1 mutations in inheritedretinal degenerative disease. Mol Genet Metab. 2000;70142- 150
PubMedArticle
29.
Akey  DTZhu  XDyer  M  et al.  The inherited blindness associated protein AIPL1 interacts with thecell cycle regulator protein NUB1. Hum Mol Genet. 2002;112723- 2733
PubMedArticle
30.
Perrault  IRozet  JMGhazi  I  et al.  Different functional outcome of RetGC1 and RPE65 gene mutations in Leber congenital amaurosis. Am J Hum Genet. 1999;641225- 1228
PubMedArticle
31.
Dharmaraj  SRSilva  ERPina  AL  et al.  Mutational analysis and clinical correlation in Leber congenital amaurosis. Ophthalmic Genet. 2000;21135- 150
PubMedArticle
32.
Lorenz  BGyurus  PPreising  M  et al.  Early-onset severe rod-cone dystrophy in young children with RPE65 mutations. Invest Ophthalmol Vis Sci. 2000;412735- 2742
PubMed
33.
Lotery  AJNamperumalsamy  PJacobson  SG  et al.  Mutation analysis of 3 genes in patients with Leber congenital amaurosis. Arch Ophthalmol. 2000;118538- 543
PubMedArticle
34.
Koenekoop  RKFishman  GAIannaccone  A  et al.  Electroretinographic abnormalities in parents of patients with Lebercongenital amaurosis who have heterozygous GUCY2D mutations. Arch Ophthalmol. 2002;1201325- 1330
PubMedArticle
35.
Marmor  MFZrenner  E Standard for clinical electroretinography (1999 update): InternationalSociety for Clinical Electrophysiology of Vision. Doc Ophthalmol. 1998-1999;97143- 156
PubMedArticle
36.
El-Shanti  HAl-Salem  MEl-Najjar  M  et al.  A nonsense mutation in the retinal specific guanylate cyclase geneis the cause of Leber congenital amaurosis in a large inbred kindred fromJordan [letter]. J Med Genet. 1999;36862- 865
PubMed
37.
Thompson  DAGyurus  PFleischer  LL  et al.  Genetics and phenotypes of RPE65 mutations in inherited retinal degeneration. Invest Ophthalmol Vis Sci. 2000;414293- 4299
PubMed
38.
Hamel  CPGriffoin  JMLasquellec  LBazalgette  CArnaud  B Retinal dystrophies caused by mutations in RPE65: assessment of visualfunctions. Br J Ophthalmol. 2001;85424- 427
PubMedArticle
39.
Koenekoop  RKLoyer  MDembinska  OBeneish  R Visual improvement in Leber congenital amaurosis and the CRX genotype. Ophthalmic Genet. 2002;2349- 59
PubMedArticle
40.
Zhang  QLi  SGuo  X  et al.  Screening for CRX gene mutations in Chinese patients with Leber congenitalamaurosis and mutational phenotype. Ophthalmic Genet. 2001;2289- 96
PubMedArticle
41.
Rivolta  CPeck  NEFulton  ABFishman  GABerson  ELDryja  TP Novel frameshift mutations in CRX associated with Leber congenitalamaurosis. Hum Mutat. 2001;18550- 551
PubMedArticle
42.
Nakamura  MIto  SMiyake  Y Novel de novo mutation in CRX gene in a Japanese patient with Lebercongenital amaurosis. Am J Ophthalmol. 2002;134465- 467
PubMedArticle
43.
Swaroop  AWang  QLWu  W  et al.  Leber congenital amaurosis caused by a homozygous mutation (R90W) inthe homeodomain of the retinal transcription factor CRX: direct evidence forthe involvement of CRX in the development of photoreceptor function. Hum Mol Genet. 1999;8299- 305
PubMedArticle
44.
van Der Spuy  JChapple  JPClark  BJ  et al.  The Leber congenital amaurosis gene product AIPL1 is localized exclusivelyin rod photoreceptors of the adult human retina. Hum Mol Genet. 2002;11823- 831
PubMedArticle
45.
Flanders  MLapointe  MLBrownstein  SLittle  JM Keratoconus and Leber's congenital amaurosis: a clinicopathologicalcorrelation. Can J Ophthalmol. 1984;19310- 314
PubMed
46.
Heher  KLTraboulsi  EIMaumenee  IH The natural history of Leber's congenital amaurosis: age-related findingsin 35 patients. Ophthalmology. 1992;99241- 245
PubMedArticle
47.
Schroeder  RMets  MBMaumenee  IH Leber's congenital amaurosis: retrospective review of 43 cases anda new fundus finding in two cases. Arch Ophthalmol. 1987;105356- 359
PubMedArticle
48.
Leighton  DAHarris  R Retinal aplasia in association with macular coloboma, keratoconus andcataract. Clin Genet. 1973;4270- 274
PubMedArticle
49.
Kennedy  RHBourne  WMDyer  JA A 48-year clinical and epidemiologic study of keratoconus. Am J Ophthalmol. 1986;101267- 273
PubMed
50.
Alström  CHOlson  O Heredo-retinopathia congenitalis monohybrida recessiva autosomalis. Hereditas. 1957;431- 178
51.
Auffarth  GUTetz  MRKrastel  HBlankenagel  AVolcker  HE Complicated cataracts in various forms of retinitis pigmentosa: typeand incidence [in German]. Ophthalmologe. 1997;94642- 646
PubMedArticle
52.
Fishman  GAAnderson  RJLourenco  P Prevalence of posterior subcapsular lens opacities in patients withretinitis pigmentosa. Br J Ophthalmol. 1985;69263- 266
PubMedArticle
×