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From the Departments of 1 Ophthalmology and 7 Pediatrics, The University of Iowa College of Medicine, Iowa City; 2 Hôpital Jules Gonin, Lausanne, Switzerland; 3 Division de Génétique Médicale, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; 4 University of Illinois Eye and Ear Infirmary, Chicago; 5 The Casey Eye Institute, Portland, Oregon; the 6 Department of Ophthalmology, Scheie Eye Institute, Philadelphia, Pennsylvania; and the 8 Howard Hughes Medical Institute, Iowa City.
| Abstract |
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METHODS. Three hundred twenty-one AMD patients, 192 ethnically similar control subjects, 39 unrelated probands with familial Best disease, and 57 unrelated probands with the ophthalmoscopic findings of Best disease but no family history were screened for sequence variations in the VMD2 gene by single-strand conformation polymorphism (SSCP) analysis. Amplimers showing a bandshift were reamplified and sequenced bidirectionally. In addition, the coding regions of the VMD2 gene were completely sequenced in six probands with familial Best disease who showed no SSCP shift.
RESULTS. Forty different probable or possible disease-causing mutations were found in one or more Best disease or AMD patients. Twenty-nine of these variations are novel. Of the 39 probands with familial Best disease, mutations were detected in all 39 (33 by SSCP and 6 by DNA sequencing). SSCP screening of the 57 probands with a clinical diagnosis of Best disease but no family history revealed 16 with mutations. Mutations were found in 5 of 321 AMD patients (1.5%), a fraction that was not significantly greater than in control individuals (0/192, 0%).
CONCLUSIONS. Patients with the clinical diagnosis of Best disease are significantly more likely to have a mutation in the VMD2 gene if they also have a positive family history. These findings suggest that a small fraction of patients with the clinical diagnosis of AMD may actually have a late-onset variant of Best disease, whereas at the same time, a considerable fraction of isolated patients with the ophthalmoscopic features of Best disease are probably affected with some other macular disease.
| Introduction |
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Best disease shares some clinical and histologic features with AMD. Both diseases are characterized by an accumulation of lipofuscin-like material within and beneath the retinal pigment epithelium.7 Geographic atrophy of the retinal pigment epithelium and choroidal neovascularization can occur in both disorders. One feature that distinguishes Best disease from AMD is an abnormality of the electro-oculogram (EOG). Normally, the electrical potential across the retinal pigment epithelium increases almost twofold when an eye moves from darkness to bright light, but in patients with Best disease, this potential changes very little, if at all, under these conditions. That this EOG abnormality is present in affected individuals with ophthalmoscopically normal maculae suggests that it is a primary rather than a secondary phenomenon. However, the mechanism by which bestrophin mutations give rise to an abnormal EOG is not known at this time.
Age-related macular degeneration is likely to be a genetically heterogeneous disease, and, given the broad phenotypic similarity to Best disease, it is plausible that a fraction of AMD cases could be caused by mutations in the VMD2 gene.2 4 8 This study was undertaken to try to identify disease-causing mutations in the VMD2 gene in individuals affected with either Best disease or AMD.
| Materials and Methods |
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All amplimers were analyzed in a standard fashion using single-strand conformation polymorphism (SSCP) analysis in a single laboratory. All SSCP gels were independently scored by a minimum of two experienced investigators. Amplimers showing a bandshift were reamplified and sequenced bidirectionally using an automated sequencer and dye-terminator chemistry (model 377; PerkinElmer, Applied Biosystems, Foster City, CA). Variants were confirmed by restriction endonuclease digestion if a restriction site polymorphism was introduced by the sequence change. The entire VMD2 coding sequence was bidirectionally sequenced in six Best probands with familial disease who failed to exhibit an SSCP shift. This resulted in the discovery of five sequence variations. The amplimers containing three of these variations (Glu300Asp, Glu300Lys, and Asp302Gly) were also sequenced in 43 control individuals. A fourth variation (Lys30Arg) is detectable by restriction digestion, and this assay was also performed in 43 control individuals. The fifth change (Tyr227Cys) was previously found in one Best disease kindred but not in 42 control individuals.6 Statistical analyses were performed with a two-tailed Fishers exact test. The study design enabled us to detect a 5% difference between the AMD and control groups with 80% power at the 0.05 significance level.
| Results |
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Some clinical information about two of the Best disease families has been published previously. Affected individuals from the family that was the subject of our original linkage study,2 including two individuals who were reported because of dramatic fluctuations in visual acuity,10 were found to harbor an Ala243Thr mutation. Another Best patient had been previously reported because of the coexistence of an inflammatory condition known as the multiple evanescent white dot syndrome.11 This individual (marked with a dot in Fig. 1A ) was found in the present study to have a Tyr227Asn change. Three other members of his family (enclosed by a box in Fig. 1A ) are noteworthy, because they illustrate the incomplete penetrance of the vitelliform phenotype that is known to occur in some individuals that carry a VMD2 mutation. The eldest of the three was first examined at age 66 because her position in the family made her an obligate carrier of a Best disease mutation. She had no visual symptoms, and her visual acuity was 20/15 OD and 20/20 OS. Fundus examination showed healthy discs and vessels and a completely normal macula (Fig. 1B) . EOG testing showed an abnormal Arden ratio. Her 44-year-old daughter was also first examined because of her obligate carrier status. She had no visual symptoms, and her visual acuity was 20/15 OU. Fundus examination showed an entirely normal macula in both eyes (Fig. 1C) . The 9-year-old grandson of the first patient was first examined because of a family history of Best disease in a great uncle, a great aunt, and several cousins (Fig. 1A) . He had no visual symptoms, and his visual acuity was 20/15 OU. However, fundus examination revealed yellow, subfoveal vitelliform lesions in both eyes (Fig. 1D) .
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| Discussion |
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Among the Best diseaseassociated mutations, we observed one (Tyr227Asn) that was associated with such marked phenotypic variability that molecularly affected individuals in two different families were found to have perfectly normal fundus examinations at ages greater than 50 years. This mutation would be a good choice for use in transgenic animal experiments designed to look for mitigator genes in different murine backgrounds. The possible disease-causing mutations present in the AMD population would also be good candidates for study at the animal model level, because the prevalence of AMD in the general population would make their pathogenicity difficult to demonstrate with statistical arguments alone. The EOG abnormalities associated with Best disease have been very tightly linked to the lipofuscin-accumulating portion of the phenotype since the EOG abnormalities were first recognized in this disease.14 15 However, the recognition of a patient with a normal EOG and a lipofuscin-accumulating phenotype (AMD) suggests that the mechanisms that underlie the lipofuscin accumulation and the EOG abnormality could be distinct. Obviously, an alternative explanation would be that the sequence variation observed in this patient may be a rare nondisease-causing polymorphism that simply meets our empiric criteria for a possible disease-causing mutation.
Apolipoprotein E, a protein involved in fatty acid metabolism, is deposited in soft drusen.16 Similarly, Petrukhin et al.5 have suggested that a defect in fatty acid metabolism results in the lipofuscin deposits seen in Best disease. However RDS and ABCR mutations also result in lipofuscin accumulation within the RPE (causing pattern dystrophy and Stargardt disease, respectively), and neither of these genes is thought to be directly involved in fatty acid metabolism. These diseases demonstrate that genes with quite different functions (a structural protein of the photoreceptor outer segment and an adenosine triphosphatebinding cassette transporter) can result in RPE dysfunction and lipofuscin accumulation. Furthermore, at the present time, no explanation has been advanced for the EOG abnormality seen in most patients with Best disease.
Homology with other known proteins can sometimes suggest functional domains or residues the mutation of which might reasonably be expected to be more pathogenic than others. The VMD2 gene is an example that this is sometimes easier said than done. The literature regarding the RFP gene family is scant,5 6 (see National Center for Biotechnology Information web site http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=1945425&form=6&db=n&Dopt=g) and the regions thought to be shared by members of the family are open to interpretation. For consistency, we used the homologies suggested by Marquardt et al.6 for the entries in Table 1 .
The low frequency of mutations in the AMD patient population (1.5%) was not significantly different from that present in the control population (0/192, 0%). Two unrelated AMD patients were found to harbor an identical nonsense mutation in codon 149. EOGs were not obtained from these patients, and thus they may represent misdiagnosed Best patients. However, nonsense mutations appear to be very rare in Best disease (http://www.uni-wuerzburg.de/humangenetics/vmd2.html).Thus, another possibility is that truncating mutations produce haploinsufficiency and a late-onset AMD phenotype. Two other AMD patients with missense changes underwent EOG testing. In one patient, who harbored an Arg105Cys sequence change, the Arden ratio was found to be normal in both eyes (2.16 OD, 1.85 OS) suggesting that this patient did not have Best disease. In another, who harbored a Glu119Gln variation and whose right fundus is depicted in Figure 2 , the Arden ratio was abnormal (1.0 OU). This patient may have Best disease resembling AMD. A further possibility is that certain bestrophin mutations produce both an AMD phenotype and EOG abnormalities. Of interest, the Glu119Gln variation has been reported to produce another nonBest disease phenotype (bulls eye maculopathy) in a 57-year-old white female.8 The latter study similarly suggested that some other rare VMD2 variants may predispose to a small fraction of AMD.8
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| Acknowledgements |
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| Footnotes |
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Submitted for publication June 28, 1999; revised September 29 and November 11, 1999; accepted December 2, 1999.
Commercial relationships policy: N.
Corresponding author: Edwin M. Stone, Department of Ophthalmology and Visual Sciences, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, Iowa 52242. edwin-stone{at}uiowa.edu
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