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1From the Academic Unit of Medical Genetics and Regional Genetics Service, St. Marys Hospital, Manchester, United Kingdom; 3Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium; 4Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium; 5Department of Ophthalmology, St-Jan General Hospital, Bruges, Belgium; 6Institute of Ophthalmology, London, United Kingdom; 7Department of Ophthalmic Research, Cole Eye Institute, Cleveland, Ohio; 8Department of Medical Genetics, Addenbrookes Hospital, Cambridge, United Kingdom; 9Exploration Fonctionelle de la Vision, Centre Hospitalier Régional Universitaire, Hôpital Roger Salengro, Lille Cedex, France; 10Academic Department of Ophthalmology, Manchester Royal Eye Hospital, Manchester, United Kingdom; 11Centre for Molecular Medicine, University of Manchester, Manchester, United Kingdom.
| Abstract |
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METHODS. A combination of linkage analysis and DNA sequencing in five families was used to identify disease-causing mutations in VMD2. The effect of these mutations on splicing was assessed using a minigene system.
RESULTS. Three pathogenic sequence alterations in VMD2 were identified in five families with nanophthalmos associated with ADVIRC. All sequences showed simultaneous missense substitutions and exon skipping.
CONCLUSIONS. VMD2 encodes bestrophin, a transmembrane protein located at the basolateral membrane of the RPE, that is also mutated in Best macular dystrophy. We support that each heterozygous affected individual produces three bestrophin isoforms consisting of the wild type and two abnormal forms: one containing a missense substitution and the other an in-frame deletion. The data showed that VMD2 mutations caused defects of ocular patterning, supporting the hypothesized role for the RPE, and specifically VMD2, in the normal growth and development of the eye.
A number of inherited retinal disorders are caused by mutations in genes expressed in the RPE. One example, Best disease or vitelliform macular dystrophy (VMD2, MIM 153700), is an autosomal dominant disorder associated with macular visual loss in late adolescence or adulthood caused by mutations in the VMD2 gene.4 The gene product, bestrophin, is a 585 amino acid transmembrane protein located at the basolateral membrane of the RPE that acts as an oligomeric chloride channel.5 Bestrophin mutations alter chloride ion-related conductance across the RPE cell membrane,5 6 and abnormal channel function may explain the abnormal electro-oculogram (EOG) seen in patients with Best disease. Almost all VMD2 sequence alterations in patients with classical Best disease are missense mutations (www.uni-wuerzburg.de/humangenetics/vmd2.html and Ref. 7 ).
Autosomal dominant vitreoretinochoroidopathy (ADVIRC) is a rare condition first described by Kaufman et al.8 It has characteristic retinal and vitreous findings, in particular a peripheral retinal circumferential hyperpigmented band, punctate white opacities in the retina, vitreous fibrillar condensation, and breakdown of the blood retinal barrier with retinal neovascularization. Since its original description, the condition has been reported several times in families of diverse origin.9 10 11 Importantly, EOG abnormalities in a subset of these families suggest that ADVIRC may represent a defect at the level of the RPE.12 Most recently, Lafaut et al.13 reported a three-generation ADVIRC pedigree in which all affected members had the characteristic retinal findings and additionally had ocular developmental abnormalities including nanophthalmos, microcornea, closed angle glaucoma, and congenital cataract.
Using this family for genetic analysis, we established linkage of an ADVIRC phenotype to the pericentromeric region of chromosome 11. The disease locus in another family with a related autosomal dominant phenotype comprising microcornea, rod-cone dystrophy, cataract, and posterior staphyloma (MRCS) also maps to this region.14 Analysis of these two families, and a further three families with similar developmental eye abnormalities and retinal dystrophy, showed that all affected members had pathogenic alterations that cause simultaneous missense substitutions and exon skipping in VMD2. Until now VMD2 was regarded as a gene that underlies Best disease, a macular dystrophy which leads to loss of vision postdevelopmentally. The data demonstrated that VMD2 mutations also underlie defects of ocular patterning, thereby supporting the hypothesized role for the RPE, and specifically VMD2, in the normal growth and development of the eye.
| Methods |
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Locations and marker order for chromosomes 5, 11, and 12 were taken from http://genome.ucsc.edu and the Genome Database (www.gdb.org). For linkage analysis, allele frequencies were used from the Genome Database. Two-point Lod scores were calculated using the MLINK package.15
DNA Sequencing
Primers were designed to amplify all coding exons including 50 to 100 bp of flanking intron sequence of VMD2 (sequence obtained from http://genome.ucsc.edu/; primers available on request). These primers were used initially to amplify genomic DNA from two affected individuals in Family 1 and an unaffected control. After sequencing (see below) and the identification of a possible disease causing mutation, DNA from other family members was amplified to confirm co-segregation. PCR reactions using Abgene Reddymix Taq (Abgene) contained 50 ng genomic DNA in a volume of 30 µL and were cycled as described in the Linkage Analysis section. PCR products were purified using Microcon columns (Millipore, Watford, UK) according to the manufacturers instructions.
Standard cycle sequencing reactions using BigDye terminator mix v1.1 (Applied Biosystems, Warrington, UK) contained 310 ng purified PCR product in 10 µL and were performed using the forward and reverse primers used for initial amplification. The sequencing reactions were then precipitated, dried, and analyzed on an ABI 3700 capillary sequencer (ABI, Foster City, CA).
The exonic regions of VMD2 were analyzed by sequencing in Families 2 to 5 and by SSCP in 68 unrelated individuals with anterior segment dysgenesis, respectively. The absence of any disease causing mutations from control individuals was confirmed by either single-stranded conformational polymorphism (SSCP) analysis or restriction digest. For SSCP/heteroduplex analysis, 5 µL PCR product was mixed with 5 µL of formamide loading dye, denatured, and separated on an 8% acrylamide/bis-acrylamide gel run at 350 V for 16 hours at 4°C and silver stained using standard methods.16
Cloning
Primers containing a 5' NdeI site were designed to amplify the exon of interest and to include approximately 250 bp of flanking intron on either side. Amplification of genomic DNA from affected individuals was carried out by PCR with Abgene Reddymix HiFidelity Taq (Abgene) containing 40 ng genomic DNA in 20 µL. PCR reaction products were cloned into the TA cloning vector pCRII (Invitrogen, Paisley, UK) as per the manufacturers instructions. Clones carrying either the mutant or wild-type allele were identified by direct sequencing. Both wild-type and mutant alleles were subcloned as NdeI fragments into a modified version of the
-globin-fibronectin-EDB minigene as described previously.17
Expression of Minigene
Plasmid (0.4 µg) was transfected into lens cell line CRL-11421 and into human embryological kidney CRL-1573 cells (ATCC, Teddington, UK) using Effectene transfection reagent (Qiagen, Crawley, UK) as per the manufacturers instructions. Cells were seeded at 2 x 105 per well in 6-well plates 24 hours before transfection. Twenty-four hours after transfection, total RNA was extracted from cells using Trizol reagent (Invitrogen) according to the manufacturers instructions. RT-PCR reactions were performed using the One-Step RT-PCR system (Invitrogen) according to the manufacturers instructions with minigene-specific primers or a combination of minigene- and VMD2-specific primers. PCR products were analyzed by agarose gel electrophoresis.
| Results |
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= 0.0; Fig. 2 ). Having demonstrated significant linkage to this region, refinement of the critical region was undertaken further using microsatellite markers (Fig. 2) . Haplotype analysis delineated a region between the flanking markers D11S4152 and D11S4139 which delineates a region of around 38 cM (35 to 73 cM; Centre for Medical Genetics genetic map, Marshfield Medical Research Foundation, Marshfield, WI; Fig. 2 ).
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Sequencing of the VMD2 coding sequence in Family 1 (of Belgian origin) revealed a missense change resulting in the substitution of valine by methionine at codon 86 in exon 4 (c.256G>A, p.V86M; Fig. 3 ). Subsequent analysis of all VMD2 exons and introns in Families 2 to 5 revealed disease-causing sequence alterations in each (Fig. 3) . The V86M substitution was also found in Family 3 (from NE France),18 and Family 4, (from Belgium, unpublished). Analysis with two intragenic microsatellite markers was consistent with this being a single ancestral mutational event in all three families (data not shown). Sequencing of affected individuals from Family 2 revealed an adenine to guanosine substitution at position 715 in exon 7 (c.715G>A, p.V239M) and a guanosine to adenine substitution at position 707 in exon 6 (c.707A>G, p.Y236C) in Family 5. All three sequence alterations fully co-segregated with all affected family members and were not present in 400 normal control chromosomes. Screening of VMD2 in 18 unrelated individuals with microphthalmia/coloboma and 50 individuals with various forms of anterior segment dysgenesis revealed no pathogenic alterations.
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| Discussion |
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These data suggested that each heterozygous affected individual produces three bestrophin isoforms. In addition to the product of the wild-type allele, each mutant allele is capable of producing two abnormal proteins, one containing a missense substitution, the other an in-frame deletion. The different phenotypes, which in Family 2 was more severe than in the other families, are likely to relate the different properties and proportions of the two mutant (i.e., substituted and truncated) isoforms. A similar mechanism was proposed by Zenker et al.21 for a patient with dual phenotypes (periventricular nodular heterotopia and frontometaphyseal dysplasia) that are presumed to result from the presence of dual isoforms of filamin a (FLNA) that are both produced by a de novo mutation which results in both exon skipping and a missense substitution. The illustration that a pathogenic missense mutation may also alter the regulation of splicing is likely to be a widely applicable disease mechanism for other disorders. It is likely that other missense substitutions within exons, in particular those altering exonic splicing regulatory elements, will also specific phenotypic consequences.
Ninety of 93 identified VMD2 mutations in patients with classical Best disease are missense mutations or small in-frame deletions (www.uni-wuerzburg.de/humangenetics/vmd2.html and Ref. 7 ). The others consist of a splice site mutation and two frameshift mutations, one of which affects the extreme C terminus of the protein. One patient who is homozygous for the mutation W93C had a phenotype consistent with Best disease.4 22 However, haploinsufficiency may result in a different phenotype. Since bestrophin acts as an oligomer,5 there is scope for dominant negative effects. We suggest that the abnormally spliced products described here have a novel deleterious effect on ocular development. Since individuals in all four families had clinical and developmental features of nanophthalmos, this suggests that a mutation of VMD2 could also underlie the original NNO1 family which has been mapped to a critical region encompassing the gene.19
The RPE is critical to ocular patterning, and its early ablation leads to arrest of eye growth and subsequent resorption of all ocular structures.1 Within the eye VMD2 is expressed in both developing and adult RPE.4 23 Although the mechanism underlying the developmental defects in the families presented here remains to be elucidated, our data support the hypothesized role for the RPE in ocular growth. Interestingly, the MITF transcription factor that is crucial for RPE differentiation and maintenance, and that is mutated in the microphthalmia mouse, regulates the expression of VMD2.24 The maintenance and health of the RPE is central to photoreceptor maintenance and to the pathogenesis of AMD, a disease that shares several characteristics with Best disease. It is unknown why patients with these mutations have evidence of a predominantly peripheral retinal phenotype and generalized photoreceptor cell death (as witnessed by the intraretinal pigment and abnormal ERGs), while patients with Best disease have cell death confined to the macular region. Until now, VMD2 has been regarded as the gene that underlies Best disease, a macular dystrophy that leads to loss of vision later in life. The observed defects of ocular growth (nanophthalmos) as a result of mutations in VMD2 therefore potentially demonstrate a common etiology for pathologic processes of development and of later-onset (macular dystrophy).
Many genes underlying ocular developmental disorders also encode proteins expressed postdevelopmentally, for example, microphthalmia (SOX2, CHX10, MITF),2 25 26 anterior segment dysgenesis (MAF, PITX2),27 28 glaucoma (LMX1B, MYOC),29 30 and congenital cataract (PITX3, PAX6).31 32 In the case of both MAF and PAX6, pathogenic mutations are known to cause both congenital (cataract and aniridia, respectively) and late-onset (progressive cortical cataract and keratitis, respectively) phenotypes in the same individuals.33 Such proteins have important roles in both the development and maintenance of mature tissues. In the context of identifying candidates for multifactorial late-onset disorders, our data suggest that the distinction between developmental and late-onset genes is artificial and that developmental genes with appropriate tissue expression should be considered as candidate genes for late-onset disorders.
Electronic Database Information
VMD2 sequence alterations: www.uni-wuerzburg.de/humangenetics/vmd2.html. Locations and marker order for chromosomes University of California Santa Cruz (http://genome.ucsc.edu) and the Genome Database (www.gdb.org). ESEFinder program (http://exon.cshl.org/ESE/index.html).
| Footnotes |
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Supported by Grant GR067443AIA from the Wellcome Trust (RP, JY). GCMB is a Wellcome Trust Senior Research Fellow in Clinical Science.
Submitted for publication May 18, 2004; accepted June 28, 2004.
Disclosure: J. Yardley, None; B.P. Leroy, None; N. Hart-Holden, None; B.A. Lafaut, None; B. Loeys, None; L.M. Messiaen, None; R. Perveen, None; M.A. Reddy, None; S.S. Bhattacharya, None; E. Traboulsi, None; D. Baralle, None; J.-J. De Laey, None; B. Puech, None; P. Kestelyn, None; A.T. Moore, None; F.D.C. Manson, None; G.C.M. Black, None
The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked "advertisement" in accordance with 18 U.S.C.
1734 solely to indicate this fact.
Corresponding author: Graeme C. M. Black, Department of Clinical Genetics, St Marys Hospital, Hathersage Road, Manchester M13 0JH, UK; gblack{at}man.ac.uk.
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