Atypical achromatopia of sex-linked recessive inheritance

Rod and rod-driven function in achromatopsia and blue cone monochromatism

PURPOSE

To evaluate rod photoreceptor and postreceptor retinal function in pediatric patients with achromatopsia (ACHR) and blue cone monochromatism (BCM) using contemporary electroretinographic (ERG) procedures.

METHODS

Fifteen patients (age range, 1-20 years) with ACHR and six patients (age range, 4-22 years) with BCM were studied. ERG responses to full-field stimuli were obtained in scotopic and photopic conditions. Rod photoreceptor (S(rod), R(rod)) and rod-driven postreceptor (log sigma, V(max)) response parameters were calculated from the a-wave and b-wave. ERG records were digitally filtered to demonstrate the oscillatory potentials (OPs); a sensitivity parameter, log SOPA(1/2), and an amplitude parameter, SOPA(max), were used to characterize the OP response. Response parameters were compared with those of 12 healthy control subjects.

RESULTS

As expected, photopic responses were nondetectable in patients with ACHR and BCM. In addition, mean scotopic photoreceptor (R(rod)) and postreceptor (V(max) and SOPA(max)) amplitude parameters were significantly reduced compared with those in healthy controls. The flash intensity required to evoke a half-maximum b-wave amplitude (log sigma) was significantly increased.

CONCLUSIONS

Results of this study provide evidence that deficits in rod and rod-mediated function occur in the primary cone dysfunction syndromes ACHR and BCM.

The cone dystrophies

The cone dystrophies are a heterogeneous group of inherited disorders that result in dysfunction of the cone photoreceptors and sometimes their post-receptoral pathways. The major clinical features of cone dystrophy are photophobia, reduced visual acuity and abnormal colour vision. Ganzfeld electroretinography shows reduced or absent cone responses. On the basis of their natural history, the cone dystrophies may be broadly divided into two groups: stationary and progressive cone dystrophies. The stationary cone dystrophies have received more attention, and subsequently our knowledge of their molecular genetic, psychophysical and clinical characteristics is better developed. Various methods of classification have been proposed for the progressive cone dystrophies, but none is entirely satisfactory, largely because the underlying disease mechanisms are poorly understood. Multidisciplinary studies involving clinical assessment, molecular genetics, electrophysiology and psychophysics should lead to an improved understanding of the pathogenesis of these disorders.

X linked progressive cone dystrophy. Localisation of the gene locus to Xp21-p11.1 by linkage analysis

Six affected males, three female carriers, and two possible carriers were evaluated from a three generation pedigree with X linked progressive cone dystrophy. The affected males presented with progressive decrease of visual acuity, impairment of colour vision, and deterioration of electroretinogram, which ranged from absent response to red light in all young patients to abnormal cone-rod responses in the elderly ones. In most affected males dark adaptation curves were monophasic and the electro-oculogram values were reduced. While some obligate carriers showed functional anomalies, they all had reduced electroretinogram response to red light. The a1/aT ratio for 1 joule white light was an appropriate indicator for carrier state. The family was studied with seven DNA markers from the proximal part of the short arm of the human X chromosome. So far, significant linkage has been found between three DNA markers and COD1, which assigns the progressive cone dystrophy gene (COD1) in this family to Xp21-p11.1. Differential diagnosis with congenital cone dystrophies is discussed.

Electroretinograms in patients with achromatopsia

Eleven patients with X-linked and 9 patients with autosomal recessive achromatopsia were examined with full-field electroretinograms. In the standard full-field ERG's, normal rod responses were obtained, but the amplitude of the cone b-waves was not detectable. With computer averaging and narrow bandpass filtering, residual cone b-wave responses could be detected in 10 of the 20 patients. The residual cone b-wave amplitudes were markedly different in the 3 families with X-linked achromatopsia. In two of them, residual cone b-wave responses were seen in all patients examined. In contrast, such responses were seen only in 2 of 7 patients in the third family. There were also differences in other clinical observations (mainly in the visual acuity and refractive error) and we therefore suggest that there are at least two forms of X-linked achromatopsia. The ratios of the cone response amplitudes to 30 Hz flickering orange and blue-green light suggested that the defect in the X-linked achromatopsia patients was of the protanope type, whereas in the autosomal patients, both the protanope and the deutanope type was seen. In conclusion, measurements of the residual cone b-wave amplitude responses are of diagnostic and may possibly be of prognostic value when examining children and other members of families with achromatopsia.

The photoreceptors in atypical achromatopsia

1. The receptoral mechanisms underlying the vision of two atypical achromats of the complete variety were studied with standard psychophysical procedures. 2. Under scotopic conditions the spectral sensitivity of each achromat was well described by the CIE (Commission Internationale de l'Eclairage) scotopic sensitivity function and the recovery of sensitivity after a retinal bleach showed characteristic duplex behaviour with the time constant of recovery of the slower phase matching that of normal rod vision for both foveal and peripheral stimulation. 3. Their spectral sensitivity was measured under conditions of chromatic adaptation in order to reveal any residual middle or long wavelength cone activity. Only one photopic spectral responses was found and this was adequately described by the spectral sensitivity function of Stiles pi 3 mechanism of normal vision. 4. Increment threshold measurements as a function of background intensity revealed a double-branched function in the fovea. The lower branch was found to have the spectral sensitivity of the rods; the upper branch that of Stiles' pi 3 mechanism. Stiles-Crawford measurements of directional sensitivity confirmed that the branch with the rhodopsin action spectrum had the directional sensitivity of rods and that the branch with the action spectrum of pi 3 had the directional sensitivity of cones. 5. These was no evidence for hue discrimination under photopic conditions. Regions of apparently normal performance on hue discrimination tests on more careful examination could be explained by luminosity judgements mediated by short wavelength-absorbing receptors. 6. We reject the notion of there being rhodopsin-filled cones in the fovea of these subjects. The foveal and peripheral vision of each of these achromats can be adequately described in terms of the participation of only two types of receptor, namely normally functional rods under scotopic conditions and normally functioning short wavelength-absorbing cones under photopic conditions. They are therefore functional blue mono-cone monochromats, an explanation which was originally proposed by Blackwell & Blackwell (1957) over thirty years ago.

X-linked myopia in Danish family

X-linked infantile myopia is described in a family of 273 members of whom 87 were examined in the National Eye Clinic. The disease may represent a new ocular syndrome, constituted by myopia combined with astigmatism, impaired vision, hypoplasia of the optic nerve heads, and deuteranopia. Obligate carriers presented slight retinal changes. Linkage studies are in progress.

[Heredity of congenital deficiencies in color vision]

The different varieties of congenital dyschromatopsias are inherited following different modes. The dyschromatopsias of the protan and deutan type, as well as the atypical achromatopsia (blue mono-cone monochromacy), are sex-linked recessive, the tritanopia probably autosomal dominant and the typical achromatopsia surely autosomal recessive. The mode of transmission of the tritanomalia is still dubious.

Concerning the localisation of the genes on the X chromosome, the bilocular theory for the deutan and protan genes is accepted at the present time. These genes form a cluster with the genes of hemophilia A and G6PD deficiency. It is possible that this cluster is situated on the short arm of the X chromosome or on the long arm near the centromeric region. The exact situation will be known very soon, when the interpretation of the results of the cellular hybridisation, which are still discordant, will be well established.