Cone-rod dystrophy. A clinical and histopathologic report

Clinical and Histopathologic Findings in Jalili Syndrome

PURPOSE

To correlate histopathologic findings in an eye with Jalili syndrome with clinical and imaging results available before enucleation.

DESIGN

Case report with histopathologic analysis.

SUBJECTS

Histopathologic analysis of an enucleated eye from a 63-year-old woman diagnosed with Jalili syndrome.

METHODS

Age at diagnosis, symptoms, personal and family history, and genetic testing results and previous retinal imaging were retrieved from the patient file. The ocular specimen was dissected, retinal sections were prepared, and analysis with hematoxylin and eosin staining and fluorescent immunohistochemistry was performed. The histopathologic findings were compared with the patient's imaging results available before enucleation.

RESULTS

The ocular specimen analyzed belonged to a 63-year-old woman with Jalili syndrome, homozygous for the likely pathogenic c.971T>C p.(Leu324Pro) variant in the CNNM4 gene (NM_020184.3). This patient had no light perception bilaterally and suffered from bilateral, painful, severe dry eye, with refractory to conservative treatment for 7 years before enucleation. At 1-month follow-up after enucleation and orbital implant placement, the socket was fully recovered, and a custom ocular prosthesis was adapted. The patient experienced total pain relief, improved quality of life, and a good cosmetic result. The histopathologic analyses revealed loss of photoreceptor cells, accumulation of autofluorescent material in the subretinal space, partial preservation of the inner retinal lamination, Müller glial cell disorganization, and increased number of microglial cells in the nuclear layers.

CONCLUSIONS

Our findings highlight the severe nature of this inherited retinal degenerative disease with significant damage to the outer retinal layers, absence of synaptic terminals, and loss of photoreceptors, indicating an advanced disease stage. The presence of microglial cells in the remaining nuclear layers suggests a role in photoreceptor degeneration. This study represents the first comprehensive description of clinical, genetic, imaging, and histopathologic findings in Jalili syndrome.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Development of an AAV-CRISPR-Cas9-based treatment for dominant cone-rod dystrophy 6

Cone-rod dystrophy 6 (CORD6) is caused by gain-of-function mutations in the GUCY2D gene, which encodes retinal guanylate cyclase-1 (RetGC1). There are currently no treatments available for this autosomal dominant disease, which is characterized by severe, early-onset visual impairment. The purpose of our study was to develop an adeno-associated virus (AAV)-CRISPR-Cas9-based approach referred to as "ablate and replace" and evaluate its therapeutic potential in mouse models of CORD6. This two-vector system delivers (1) CRISPR-Cas9 targeted to the early coding sequence of the wild-type and mutant GUCY2D alleles and (2) a CRISPR-Cas9-resistant cDNA copy of GUCY2D ("hardened" GUCY2D). Together, these vectors knock out ("ablate") expression of endogenous RetGC1 in photoreceptors and supplement ("replace") a healthy copy of exogenous GUCY2D. First, we confirmed that ablation of mutant R838S GUCY2D was therapeutic in a transgenic mouse model of CORD6. Next, we established a proof of concept for "ablate and replace" and optimized vector doses in Gucy2e+/-:Gucy2f-/- and Gucy2f-/- mice, respectively. Finally, we confirmed that the "ablate and replace" approach stably preserved retinal structure and function in a novel knockin mouse model of CORD6, the RetGC1 (hR838S, hWT) mouse. Taken together, our results support further development of the "ablate and replace" approach for treatment of CORD6.

Motion-based super-resolution in the peripheral visual field

Improvements in foveal acuity for moving targets have been interpreted as evidence for the ability of the visual system to combine information over space and time, in order to reconstruct the image at a higher resolution (super-resolution). Here, we directly test whether this occurs in the peripheral visual field and discuss its potential for improving functional capacity in ocular disease. The effect of motion on visual acuity was first compared under conditions in which performance was limited either by natural undersampling in the retinal periphery or by the presence of overlaid masks with opaque elements to simulate retinal loss. To equate the information content of moving and static sequences, we next manipulated the dynamic properties of the masks. Finally, we determined the dependence of motion-related improvements on the object of motion (target or mask) and its trajectory (smooth or jittered). Motion improved visual acuity for masked but not unmasked peripheral targets. Equating the information content of moving and static conditions removed some but not all of this benefit. Residual motion-related improvements were largest in conditions in which the target moved along a consistent and predictable path. Our results show that motion can improve peripheral acuity in situations in which performance is limited by abnormal undersampling. These findings are consistent with the operation of a super-resolution system and could have important implications for any pathology that alters the regular sampling properties of the retinal mosaic.

Structures and biogenetic analysis of lipofuscin bis-retinoids

Age-related macular degeneration (AMD) is still an incurable blinding eye disease because of complex pathogenic mechanisms and unusual diseased regions. With the use of chemical biology tools, great progress has been achieved in improving the understanding of AMD pathogenesis. The severity of AMD is, at least in part, linked to the non-degradable lipofuscin bis-retinoids in retinal pigment epithelial (RPE). This material is thought to result from the lifelong accumulation of lysosomal residual bodies containing the end products derived from the daily phagocytosis of rod outer segments by RPE cells. Here, we present previously recognized bis-retinoids with focus on structures and biosynthetic pathways. In addition to a brief discussion on the mutual conversion relationships of bis-retinoids, future perspectives and the medical relevance of such studies on these lipofuscin constituents are also highlighted.

Retinal photodamage mediated by all-trans-retinal

Accumulation of all-trans-retinal (all-trans-RAL), reactive vitamin A aldehyde, is one of the key factors in initiating retinal photodamage. This photodamage is characterized by progressive retinal cell death evoked by light exposure in both an acute and chronic fashion. Photoactivated rhodopsin releases all-trans-RAL, which is subsequently transported by ATP-binding cassette transporter 4 and reduced to all-trans-retinol by all-trans-retinol dehydrogenases located in photoreceptor cells. Any interruptions in the clearing of all-trans-RAL in the photoreceptors can cause an accumulation of this reactive aldehyde and its toxic condensation products. This accumulation may result in the manifestation of retinal dystrophy including human retinal degenerative diseases such as Stargardt's disease and age-related macular degeneration. Herein, we discuss the mechanisms of all-trans-RAL clearance in photoreceptor cells by sequential enzymatic reactions, the visual (retinoid) cycle, and potential molecular pathways of retinal photodamage. We also review recent imaging technologies to monitor retinal health status as well as novel therapeutic strategies preventing all-trans-RAL-associated retinal photodamage.

WITHDRAWN: Ultrastructure of the human retina in aging and various pathological states

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Detection of photoreceptor disruption by adaptive optics fundus imaging and Fourier-domain optical coherence tomography in eyes with occult macular dystrophy

Purpose:

To investigate the structural changes in the photoreceptors by adaptive optics (AO) fundus imaging and Fourier-domain optical coherence tomography (FD-OCT) in eyes with occult macular dystrophy (OMD).

Design:

Observational case reports.

Methods:

Eight eyes of four patients who were diagnosed with OMD were examined. All eyes had a complete ophthalmological examination. Multifocal electroretinograms (mfERGs) were recorded from all eyes. AO and FD-OCT images of foveal photoreceptors were obtained.

Results:

The best-corrected visual acuity (BCVA) of these eyes ranged from 20/20 to 20/200, and the ocular fundus was normal by conventional ocular examination in all eyes. The amplitudes of the mfERGs were decreased in the foveal area. The inner and outer segment (IS/OS) junction of the photoreceptors in the foveal area was disrupted. The IS/OS junction was intact in one eye with a BCVA of 20/20, and the outer segment layer between the IS/OS junction and retinal pigment epithelium of the FD-OCT images was identified only in the center of the fovea. The AO images showed patchy dark areas in all eyes, which indicated a disruption of the mosaic of bright spots in the fovea.

Conclusion:

Structural changes of photoreceptors in OMD patients were detected tangentially by FD-OCT and en face by AO.

Compositional studies of human RPE lipofuscin: mechanisms of molecular modifications

The accumulation of lipofuscin has previously been implicated in several retinal diseases including Best's macular dystrophy, Stargardt's disease and age-related macular degeneration (AMD). Previously one of the major fluorophores of lipofuscin was identified as a bis-retinoid pyridinium salt called A2E, which is known to photochemically cause damage. In addition to A2E, there are numerous components in RPE lipofuscin that are unidentified. These compounds were determined to be structurally related to A2E by their fragmentation pattern with losses of 106, 190, 174 and/or 150 amu from the parent ion and the formation of fragments of ca 592 amu. The vast majority consists of relatively hydrophobic components corresponding to derivatized A2E with molecular weights in discrete groups of 800-900, 970-1080 and > 1200 m/z regions. In order to determine the mechanism of these modifications, A2E was chemically modified by; (1) the formation of specific esters, (2) reaction with specific aldehydes and (3) spontaneous auto-oxidation. The contribution of ester formation to the naturally occurring components of lipofuscin was discounted since their fragmentation patterns were different to those found in vivo. Alternatively, reactions with specific aldehydes result in nearly identical products as those found in vivo. Artificial aging of RPE lipofuscin gives a complex mixture of structurally related components. This results from the auto- and/or photooxidation of A2E to form aldehydes, which then back react with A2E giving a series of higher molecular weight products. The majority of these modifications result in compounds that are much more hydrophobic than A2E. These higher molecular weight materials have increased values of log P compared to A2E. This increase in hydrophobicity most likely aids in the sequestering of A2E into granules with the concomitant diminution of its reactivity. Therefore, these processes may serve as protective mechanisms for the RPE.

Optical coherence tomography findings in a case of cone-rod dystrophy

A patient with cone-rod dystrophy, who was examined thoroughly with biomicroscopy, fluorescein angiography, optical coherence tomography, and electrophysiology, is presented. Although fluorescein angiography depicted only window-defect type of hyperfluorescence, optical coherence tomography disclosed detachment of the neurosensory retina, focal absence of the outer parts of the photoreceptors' layer in the fovea, and cystoid edema in the macula. To the authors' knowledge, these findings have not been described in cone-rod dystrophy so far.

Compositional studies of human RPE lipofuscin

Age-related macular degeneration (AMD) is an ocular disease that causes visual loss and legal blindness in the elderly population. The etiology of AMD is complex and may include genetic predispositions, accumulation of lipofuscin and drusen, local inflammation and neovascularization. The accumulation of lipofuscin has been shown to precede the death of photoreceptor cells and the deterioration of the RPE. As a result, the determination of the photosensitive components of lipofuscin has been of major interest. One of these components, previously identified as a bis-retinoid pyridinium compound, is referred to as A2E. A2E has been characterized by mass spectrometry and is known to have a mass of 592 Da. Most remaining chromophores in RPE lipofuscin are structurally related to A2E as determined by their fragmentation pattern with losses of M ± 190, 174 and/or 150 Da. Analysis of lipofuscin from various donors indicated that the extracts consist of as many as 15 of these hydrophobic components, which are also observed to form spontaneously in vitro over extended periods of time. These consist of ca 90% of the A2E-like components in RPE lipofuscin and correspond to derivatized A2E with discrete molecular weights of 800-900 m/z, 970-1080 m/z and above 1200 m/z regions. It was determined that these species are formed from self-reaction of A2E oxidation products or their reaction with A2E itself to form higher molecular weight products. The majority of modifications are much more hydrophobic than A2E and exhibit increasingly higher values of log P. This acts as a driving force for the sequestering of A2E into granules resulting in a concomitant diminution of its reactivity in vivo.

Abnormal Distribution of Red/Green Cone Opsins in a Patient with an Autosomal Dominant Cone Dystrophy

PURPOSE

To define the distribution of the red/green and blue opsins in cones from donor eyes from an affected member of a clinically well-characterized family with an autosomal dominant form of cone dystrophy.

METHODS

Tissue was fixed and processed for immunohistochemistry. Cryosections were studied by indirect immunofluorescence, using well-characterized antibodies to cone cytoplasm, rhodopsin, and cone opsins. The cone-associated matrix was also labeled with the lectin PNA. The affected donor eyes were compared to a postmortem matched normal eye.

RESULTS

Electroretinogram (ERG) testing three years prior to the affected member's death showed normal rod function, while the cone b-wave amplitude was reduced 40% below the lower limit of normal. Fundus exam showed only isolated drusen within the macula. Either a normal-appearing or only nonspecific macular findings were noted in the other affected family members who were examined. Immunofluorescence studies showed that blue cone opsin was restricted to the outer segments of blue cones in the affected retina. Red/green opsins were distributed along the entire plasma membrane of these cone types, from the tip of the outer segment to the synaptic base. Cone-associated matrix displayed a heterogeneous distribution. These patterns were observed both in the macula and in the periphery of the affected retina. Cone pedicles appeared larger than normal. In contrast, rhodopsin staining appeared normal.

CONCLUSIONS

The immunocytochemical data obtained suggest that the clinical manifestation of this dystrophy is associated with an abnormal distribution of cone red/green opsins. Additionally, changes in the cone pedicles could have contributed to the abnormal cone ERG in this patient.

Isolation and characterization of a spontaneously immortalized bovine retinal pigmented epithelial cell line

BACKGROUND

The Retinal Pigmented Epithelium (RPE) is juxtaposed with the photoreceptor outer segments of the eye. The proximity of the photoreceptor cells is a prerequisite for their survival, as they depend on the RPE to remove the outer segments and are also influenced by RPE cell paracrine factors. RPE cell death can cause a progressive loss of photoreceptor function, which can diminish vision and, over time, blindness ensues. Degeneration of the retina has been shown to induce a variety of retinopathies, such as Stargardt's disease, Cone-Rod Dystrophy (CRD), Retinitis Pigmentosa (RP), Fundus Flavimaculatus (FFM), Best's disease and Age-related Macular Degeneration (AMD). We have cultured primary bovine RPE cells to gain a further understanding of the mechanisms of RPE cell death. One of the cultures, named tRPE, surpassed senescence and was further characterized to determine its viability as a model for retinal diseases.

RESULTS

The tRPE cell line has been passaged up to 150 population doublings and was shown to be morphologically similar to primary cells. They have been characterized to be of RPE origin by reverse transcriptase PCR and immunocytochemistry using the RPE-specific genes RPE65 and CRALBP and RPE-specific proteins RPE65 and Bestrophin. The tRPE cells are also immunoreactive to vimentin, cytokeratin and zonula occludens-1 antibodies. Chromosome analysis indicates a normal diploid number. The tRPE cells do not grow in suspension or in soft agar. After 3H thymidine incorporation, the cells do not appear to divide appreciably after confluency.

CONCLUSION

The tRPE cells are immortal, but still exhibit contact inhibition, serum dependence, monolayer growth and secrete an extra-cellular matrix. They retain the in-vivo morphology, gene expression and cell polarity. Additionally, the cells endocytose exogenous melanin, A2E and purified lipofuscin granules. This cell line may be a useful in-vitro research model for retinal maculopathies.

Increasing exotropia and decreasing vision in a school-aged boy

An 8-year-old boy presented with bilateral visual loss and an increasing exotropia, and later developed deteriorating school performance. Magnetic resonance imaging of the head showed bilateral, symmetric, T2, and FLAIR white matter abnormalities in the parieto-occipital regions. Elevated serum very long chain fatty acids confirmed the diagnosis of X-linked adrenoleukodystrophy. Ophthalmologists should be aware of the diagnosis in boys with visual loss, hyperactivity, behavioral changes, and deterioration in school performance. Visual loss may be the presenting or predominant feature in X-linked adrenoleukodystrophy.

Protective effects of myricetin and related flavonols against A2E and light mediated-cell death in bovine retinal primary cell culture

The present study was performed to investigate the effect of flavonols, namely myricetin and structurally related quercetin and kaempferol against A2E and blue light-induced photoreceptors death in primary retinal cell cultures. Primary retinal cell cultures were prepared from bovine retinas. Fourteen-day-old cultures were pretreated with different concentrations of myricetin, quercetin, kaempferol (1-40 microM) for 24 h, then treated with 30 microM of A2E or exposed to blue-actinic light for 20 h. Green nucleic acid stain assay was used to evaluate cell death. Photoreceptor and bipolar cells were immunolabeled with specific antibodies and were counted using automated microscope imaging and image-based cell counting software. Twenty hours exposure to blue light induced approximately 75% death of photoreceptors in bovine retinal cell cultures. Myricetin protected 100% of photoreceptors against blue-light-mediated damage with an EC(50) of 9+/-0.7 microM. Quercetin resulted in a maximum of 15% protection against light damage, and kaempferol was inactive. A2E induced photoreceptor and bipolar cell death in a concentration-dependent manner with EC(50) of 25 microM for photoreceptors and 31 microM for bipolar cells. Myricetin, quercetin and kaempferol protected against A2E-induced photoreceptors and bipolar cells death with EC(50) values of 2+/-0.3 microM, 2+/-0.3 microM, 5+/-0.09 microM and 0.8+/-0.07 microM, 0.44+/-0.06 microM, 1+/-0.4 microM, respectively. Caspase-3 inhibitor (Z-DEVD-fmk) protected 42% photoreceptors and 57% bipolar cells from A2E toxicity. In contrast, this inhibitor had no effect against light-induced photoreceptor damage. Despite the poor activity of quercetin and the inactivity of kaempferol against blue light, myricetin, quercetin and kaempferol exhibited approximately 100% protection against A2E toxicity. This suggests that light- and A2E-induced cell deaths are mediated through different pathways. These results suggest that myricetin functions as potent and effective neuroprotective agent for photoreceptor cells against A2E and light damage.

Transplantation of the RPE in AMD

The retinal pigment epithelium (RPE) maintains retinal function as the metabolic gatekeeper between photoreceptors (PRs) and the choriocapillaries. The RPE and Bruch's membrane (BM) suffer cumulative damage over lifetime, which is thought to induce age-related macular degeneration (AMD) in susceptible individuals. Unlike palliative pharmacologic treatments, replacement of the RPE has a curative potential for AMD. This article reviews mechanisms leading to RPE dysfunction in aging and AMD, laboratory studies on RPE transplantation, and surgical techniques used in AMD patients. Future strategies using ex vivo steps prior to transplantation, BM prosthetics, and stem cell applications are discussed. The functional peculiarity of the macular region, epigenetic phenomena leading to an age-related shift in protein expression, along with the accumulation of lipofuscin may affect the metabolism in the central RPE. Thickening of BM with age decreases its hydraulic conductivity. Drusen are deposits of extracellular material and formed in part by activation of the alternative complement pathway in individuals carrying a mutant allele of complement factor H. AMD likely represents an umbrella term for a disease entity with multifactorial etiology and manifestations. Presently, a slow progressing (dry) non-neovascular atrophic form and a rapidly blinding neovascular (wet) form are discerned. No therapy is currently available for the former, while RPE transplantation and promising (albeit non-causal) anti-angiogenic therapies are available for the latter. The potential of RPE transplantation was demonstrated in animal models. Rejection of allogeneic homologous transplants in patients focused further studies on autologous sources. In vitro studies elucidated cell adhesion and wound healing mechanisms on aged human BM. Currently, autologous RPE, harvested from the midperiphery, is being transplanted as a cell suspension or a patch of RPE and choroid in AMD patients. These techniques have been evaluated from several groups. Autologous RPE transplants may have the disadvantage of carrying the same genetic information that may have led to AMD manifestation. An intermittent culturing step would allow for in vitro therapy of the RPE, its rejuvenation and prosthesis of BM to improve the success RPE transplants. Recent advances in stem cell biology when combined with lessons learned from studies of RPE transplantation are intriguing future therapeutic modalities for AMD patients.

High-Resolution Retinal Imaging of Cone–Rod Dystrophy

PURPOSE

This study examines a patient with cone-rod dystrophy using high-resolution adaptive optics retinal imaging. Conventional ophthalmoscopes provide limited resolution due to their inability to overcome the eye's optical aberrations. In contrast, adaptive optics ophthalmoscopes correct these aberrations to provide noninvasive high-resolution views of the living retina. To date, adaptive optics ophthalmoscopy has been used mainly to examine the normal retina. Here we use adaptive optics ophthalmoscopy to image cone-rod dystrophy in vivo and compare these results with standard clinical tests.

DESIGN

Observational case report.

METHODS

High-resolution retinal images of a patient with cone-rod dystrophy were obtained with the University of Rochester adaptive optics flood-illuminated ophthalmoscope and the adaptive optics scanning laser ophthalmoscope located at the University of Houston and compared with standard clinical tests, including fundus photography, Goldmann visual fields, fluorescein angiography, optical coherence tomography, electroretinography, and multifocal electroretinography.

MAIN OUTCOME MEASURES

Direct measurement of cone density and diameter and comparison of adaptive optics images with standard clinical imaging and functional tests.

RESULTS

Adaptive optics images were acquired at multiple retinal locations throughout a clinically detected bull's-eye lesion. Within the atrophic regions, we observed large areas devoid of wave-guiding cones. In contrast, regions that appeared relatively spared by clinical examination contained a completely tiled cone mosaic. However, in these areas the cones were abnormally large, resulting in a 6.6-fold reduction from the normal peak cone density (patient peak density: 30 100 cones/mm2, normal peak density: 199 200 cones/mm2). Multifocal electroretinography confirmed a 5.5-fold reduction in amplitude of the central peak (10.8 nanovolts/degree2 vs. 59.8 nanovolts/degree2).

CONCLUSIONS

Adaptive optics ophthalmoscopy is a noninvasive technique to observe a patient's retinal pathology directly at a cellular level. It can provide a quantitative measurement of photoreceptor loss in retinal disease.

RPE lipofuscin and its role in retinal pathobiology

Emerging evidence indicates that the autofluorescent pigments that accumulate as lipofuscin in retinal pigment epithelial (RPE) cells may reach levels that contribute to a decline in cell function. Since recent findings with respect to the origin, composition and adverse effects of RPE lipofuscin have informed our view of this material, the goal of this article is to review our current understanding of these issues.

Biosynthetic studies of A2E, a major fluorophore of retinal pigment epithelial lipofuscin

We have examined questions related to the biosynthesis of A2E, a fluorophore that accumulates in retinal pigment epithelial cells with aging and in some retinal disorders. The use of in vitro preparations revealed that detectable levels of A2-PE, the A2E precursor, are formed within photoreceptor outer segments following light-induced release of endogenous all-trans-retinal. Moreover, experiments in vivo demonstrated that the formation of A2-PE in photoreceptor outer segment membrane was augmented by exposing rats to bright light. Whereas the generation of A2E from A2-PE by acid hydrolysis was found to occur very slowly, the detection in outer segments of a phosphodiesterase activity that can convert A2-PE to A2E may indicate that some portion of the A2-PE that forms in the outer segment membrane may undergo hydrolytic cleavage before internalization by the retinal pigment epithelial cell. The identities of additional minor components of retinal pigment epithelium lipofuscin, A2E isomers with cis olefins at positions other than the C13-C14 double bond, are also described.

Fluorescent pigments of the retinal pigment epithelium and age-related macular degeneration

The major hydrophobic fluorophore of the retinal pigment epithelium (RPE) is A2E, a pyridinium bis-retinoid derived from all-trans-retinal and phosphatidyl-ethanolamine. The accumulation of fluorophores such as A2E is implicated in the pathogenesis of age-related macular degeneration (AMD), a disease associated with the deterioration of central vision and a leading cause of blindness in the elderly. Recent chemical and biological studies have provided insight into the synthesis and biosynthesis of A2E, the spectroscopic properties of this pigment, and the role of A2E and RPE cell death.

Differential diagnosis of hereditary pigmentary maculopathies

The hereditary pigmentary macular dystrophies rank among the most challenging diagnostic entities in optometric practice. Patients with these disorders can present with clinical characteristics along a broad spectrum, ranging from normal fundus findings to profound macular changes, with or without reduction in visual function. This paper reviews the key differentiating aspects of this group of disorders, including clinical testing and management strategies.

Abnormal cone synapses in human cone-rod dystrophy

OBJECTIVE

Little is known of the cytopathology of photoreceptors in human inherited retinal dystrophies that initially affect the central retina, including the macula. The current study sought to determine the cytologic features of dysfunctional cone and rod photoreceptors, as well as the pattern of degeneration of the cells in representative cases of central retinal dystrophy.

STUDY DESIGN

Comparative human tissue study.

MATERIALS

Four human donor eyes with the following forms of central retinal dystrophy: cone-rod dystrophy (CRD), central areolar choroidal dystrophy, Bardet-Biedl syndrome, and cone dystrophy-cerebellar ataxia. The cytologic features of retinal photoreceptors in these eyes were compared with those in an eye with retinitis pigmentosa and six normal human eyes.

METHODS AND OUTCOME MEASURES

Immunocytochemistry and electron microscopy were used to evaluate the retinal histopathology in the donor eyes.

RESULTS

Cone numbers were decreased in the case of CRD, particularly in the central and far peripheral retina, and both cone and rod outer segments were slightly shortened. Occasional degenerate cones had dense cytoplasm and pyknotic nuclei dislocated sclerad to the external-limiting membrane. The most prominent alteration in this retina was marked enlargement and distortion of the cone photoreceptor pedicles, which contained reduced numbers of synaptic vesicles. The retina with central areolar choroidal dystrophy contained a few cones with similarly abnormal synapses. However, comparable cone synapse abnormalities were not observed in the cases of Bardet-Biedl syndrome, cone dystrophy-cerebellar ataxia, retinitis pigmentosa, or in the normal retinas.

CONCLUSIONS

The functional consequences of the cone synapse abnormalities in CRD are not known but may correlate with the electroretinographic abnormalities documented in some cases of CRD. To our knowledge, comparable synapse changes have not been noted in either rods or cones in other forms of retinal dystrophy, including retinitis pigmentosa, suggesting that different cytopathologic mechanisms may be involved.

Prolonged rod dark adaptation in patients with cone-rod dystrophy

Thirteen patients with cone-rod dystrophy were assigned into one of four previously described category subtypes according to clinical, electrophysiologic, and psychophysical criteria. The time course of rod dark adaptation was determined for each patient by means of a Goldmann-Weekers dark adaptometer. Nine of the 13 patients showed a normal time to return to their dark-adapted thresholds before bleaching, while four patients showed a prolonged recovery time. The four patients with a prolonged rod-recovery time were all from the same clinical subtype and showed a similar fundus appearance as well as similar electrophysiologic and psychophysical findings.

A gene for Stargardt's disease (fundus flavimaculatus) maps to the short arm of chromosome 1

Stargardt's disease (fundus flavimaculatus) is one of the most frequent causes of macular degeneration in childhood and accounts for 7% of all retinal dystrophies. It is an autosomal recessive condition characterized by a bilateral loss of central vision occurring at age 7-12 years. Genetic linkage analysis of eight families has assigned the disease locus to chromosome 1p21-p13. Multipoint linkage analysis and haplotype analysis has allowed us to establish the best estimate for location of the gene over the locus D1S435 (maximum lod score of 12.66). Our results are consistent with the genetic homogeneity of this condition.

Optic disc pallor: a false localizing sign

A 20-year-old pregnant woman was referred with bilateral mild visual acuity loss and optic disc pallor. Because of profound color vision deficits out of proportion to her acuity loss, an abnormality of the cone photoreceptors was suspected. An electroretinogram confirmed the diagnosis of a cone dystrophy and precluded further costly and invasive testing. Cone dystrophy should be considered in the differential diagnosis of any patient with bilateral, nonrefractive visual loss, especially if color vision is disproportionately affected, even with a normal retinal appearance and no significant family history.

Idiopathic photoreceptor dysfunction causes unexplained visual acuity loss in later adulthood

Progressive visual loss, caused by initially unrecognized retinal photoreceptor dysfunction predominantly affecting cones, developed in six patients in late adulthood. Because of minimal ophthalmoscopic retinal abnormalities, the patients initially had been suspected of having optic neuropathy or psychogenic visual loss. The correct diagnosis was ultimately established by finding electroretinographic abnormalities and color discrimination losses out of proportion to visual acuity loss. In no case was a causative agent or a family history of photoreceptor disease identified. In many other respects, however, features of the patients' illness resemble those described previously under the headings of cone dysfunction syndrome, cone dystrophy, cone degeneration, and cone-rod dystrophy.

Autosomal-dominant fundus flavimaculatus. Clinicopathologic correlation

The authors report the first clinicopathologic study of autosomal-dominant fundus flavimaculatus with late-onset atrophic macular degeneration in a 62-year-old man. Results of histopathologic examination disclosed the retinal pigment epithelium (RPE) to be distended by a periodic acid-Schiff (PAS)-positive, acid mucopolysaccharide-negative material. Transmission electron microscopy showed marked accumulation of lipofuscin and melanolipofuscin granules within the RPE. The different modes of genetic transmission and ultrastructural heterogeneity suggest that fundus flavimaculatus is a clinical syndrome representing several genetically and mechanistically distinct disorders whose common end-stage is a topographically similar accumulation of lipofuscin.

Progressive cone-rod dystrophy and high myopia in a Finnish family

Progressive cone-rod dystrophy was diagnosed in a 35-year-old man (the proband). In the family study, 29 of the relatives were examined. The brother of the proband was also found to have cone-rod dystrophy. In the family of the mother of the proband, there were four men who had high myopia possibly connected with cone-rod dystrophy. The other relatives had no signs of cone-rod dystrophy or high myopia. The relatives not examined were reported healthy with no eye trouble. The disorder could be autosomal recessive hereditary if only the confirmed cone-rod dystrophy of the proband and his brother is taken in consideration. However, no relationships between the families of the mother and father of the proband could be found going back to the year 1830. Therefore, the autosomal recessive inheritance was not established. The most probable mode of inheritance would be X-chromosomal recessive if high myopia and cone-rod dystrophy are thought to be parts of the same syndrome.

Variable expressivity in fundus albipunctatus

A healthy, 14-year-old girl presented with nyctalopia, good vision, and multiple, irregular, yellowish lesions of the fundus. Dark adaptometry showed prolonged cone and rod branches, elevated thresholds, and the cone-rod transition occurring after 50 minutes in darkness. Her scotopic electroretinogram (ERG) b-wave attained normal amplitudes after 45 minutes of dark adaptation. The half-time for regeneration of rhodopsin after an extensive bleach was 16 minutes, four times longer than normal, and the maximum density difference measured by fundus reflectometry was at the lower limit of the normal range. Although photopigment kinetics were significantly faster than observed in other reported cases of fundus albipunctatus, it appears likely that there is a wide spectrum of functional and funduscopic abnormalities in this disorder. However, fundus appearance, adaptometric findings, and rhodopsin determinations serve to distinguish fundus albipunctatus from other flecked retina diseases.