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Su G, Chen XW, Pan JL, Li H, Xie B, Cai SJ. Clinical features of retinal amyloid angiopathy with transthyretin Gly83Arg variant. Int J Ophthalmol 2023; 16:128-134. [PMID: 36659956 PMCID: PMC9815990 DOI: 10.18240/ijo.2023.01.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/25/2022] [Indexed: 12/29/2022] Open
Abstract
AIM To report on the clinical features of patients with retinal amyloid angiopathy (RAA) who were identified to be caused by the transthyretin (TTR) Gly83Arg variant. METHODS Case series of five patients diagnosed with RAA was collected at Affiliated Hospital of Zunyi Medical University from January 2010 to December 2021. The clinical features, therapeutic strategies, and prognoses of all patients were reviewed. RESULTS Five patients with a mean age of 52.00±7.23y were diagnosed as RAA. These patients were previously diagnosed with hereditary transthyretin amyloidosis caused by the TTR Gly83Arg variant. Vitreous opacity was found in all 10 eyes, and 7 eyes developed RAA 2 to 20y after the onset of hereditary transthyretin amyloidosis. The clinical manifestations were recurrent vitreous hemorrhage in 2 eyes (29%), neovascular glaucoma in 2 eyes (29%), and iris neovascularization in 1 eye (14%). Microangioma lesions were found in all affected eyes that underwent fundus fluorescein angiography (FFA) in this group of cases, and the incidence of the retinal non-perfusion area was 67%. Although no cases of retinal neovascularization were found, the prognosis of visual acuity was not ideal. CONCLUSION This is the first report of RAA in patients with the TTR Gly83Arg variant. Complications such as RAA and glaucoma will seriously affect the visual prognosis of patients. Thereafter, regular ophthalmic follow-up of patients with hereditary transthyretin amyloidosis is essential. And FFA after vitrectomy is very important, which can help ophthalmologists detect RAA earlier and treat it in time.
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Affiliation(s)
- Gang Su
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China
| | - Xing-Wang Chen
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China,Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Jun-Lin Pan
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China
| | - Hong Li
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China,Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Bing Xie
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China,Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Shan-Jun Cai
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China,Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China,Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China,Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China; Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China; Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China
| | - Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China; Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China; Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China; Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China; Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China; Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China; Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
| | - Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China; Guizhou Eye Hospital, Zunyi 563000, Guizhou Province, China; Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi 563000, Guizhou Province, China; Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi 563000, Guizhou Province, China
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Shen J, Yu H, Lin J, Zhang L, Pan X, Chen Z. Case Report: Hereditary transthyretin (ATTRv) amyloidosis: The p.G103R mutation of the transthyretin gene in a Han Chinese family is associated with vitreous hemorrhage. Front Genet 2022; 13:972501. [PMID: 36186469 PMCID: PMC9520364 DOI: 10.3389/fgene.2022.972501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis is a rare disease caused by transthyretin gene (TTR) mutation. We identified that the p.G103R mutation of the TTR gene in a Han Chinese family was associated with vitreous hemorrhage. The proband was a 48-year-old woman who had progressive visual impairment in both eyes for 12 years. A Glass wool–like posterior vitreous cortex attached to the posterior retinal surface of both eyes was found using ocular coherence tomography. Visual acuity improved after the first vitrectomy. Two years later, the patient underwent two more vitrectomies because of vitreous opacity recrudescence. Four years later, she presented with vitreous hemorrhage in the right eye. The vitreous fluids acquired during the vitrectomy showed increased vascular endothelial growth factor, basic fibroblast growth factor, interleukin-6, interleukin-10, vascular cell adhesion molecule, and interleukin-8. Mutation sequencing revealed a heterozygous mutation in nucleotide c.307G > C (p.G103R) in exon 3 of the TTR gene in the proband (IV-13), her daughter (IV-9), and her fourth sister (III-11). To our knowledge, this is the first case of ATTRv amyloidosis caused by a p.G103R mutation of the TTR gene associated with vitreous hemorrhage in China.
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Affiliation(s)
- Junhui Shen
- Eye Center, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Yu
- Department of Neurology and Department of Medical Genetics in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Jijian Lin
- Eye Center, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Zhang
- Eye Center, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaohong Pan
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiqing Chen
- Eye Center, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Zhiqing Chen,
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Marques JH, Coelho J, Menéres MJ, Melo Beirão J. Monitoring the Patient with Retinal Angiopathy Associated with Hereditary Transthyretin Amyloidosis: Current Perspectives. Clin Ophthalmol 2022; 16:2227-2233. [PMID: 35844663 PMCID: PMC9278722 DOI: 10.2147/opth.s359312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Retinal angiopathy associated with hereditary transthyretin amyloidosis (ATTRv), if untreated, may lead to irreversible vision loss. Our purpose was to systematically review the clinical and imaging features of retinal angiopathy associated with ATTRv and assemble a monitoring approach for these patients. All types of original research studies reporting clinical and imaging findings on retinal angiopathy associated with ATTRv were included. The most common clinical findings were tortuous retinal vessels, microaneurysms, retinal hemorrhages, sheathing of retinal vessels, whitish amyloid deposits along retinal arteries, obliteration of retinal vessels, vitreous hemorrhage, retinal and iris neovascularization. The most relevant imaging findings were hyperautofluorescence of perivessel amyloid deposits; delayed arterial filling, vascular leakage, and retinal ischemia on fluorescein angiography; late hypercyanescence along the choroidal arteries on indocyanine green angiography; perivascular hyperreflective material, needle-shaped deposits on the retinal surface and macular edema on optical coherence tomography (OCT) and attenuated retinal vascular network on OCT-angiography. ATTRv patients should be strictly followed to detect and treat retinal angiopathy, avoiding complications. Both panretinal photocoagulation and intravitreal anti-vascular endothelial growth factor have been used to treat retinal angiopathy in ATTRv. In an individual that presents with retinal angiopathy of unknown etiology, ATTRv should be considered as in the differential diagnosis, even out of the initial core countries. The prognostic value of subclinical findings, namely in OCT-A, is not yet established.
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Affiliation(s)
- João Heitor Marques
- Serviço de Oftalmologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Correspondence: João Heitor Marques, Serviço de Oftalmologia, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal, Tel +351913680736, Email
| | - João Coelho
- Serviço de Oftalmologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Menéres
- Serviço de Oftalmologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - João Melo Beirão
- Serviço de Oftalmologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Gonçalves AN, Lima LH, Balaratnasingam C, Agarwal A, Jorge R. VITREOUS HEMORRHAGE IN A PATIENT WITH POLYNEUROPATHY. Retin Cases Brief Rep 2021; 15:S42-S44. [PMID: 34171903 DOI: 10.1097/icb.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Annelise N Gonçalves
- Department of Ophthalmology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto/São Paulo, Brazil
| | - Luiz H Lima
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Chandrakumar Balaratnasingam
- Center for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
- Department of Ophthalmology, Sir Charles Gairdner Hospital, Western Australia, Australia; and
| | | | - Rodrigo Jorge
- Department of Ophthalmology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto/São Paulo, Brazil
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Gião T, Saavedra J, Vieira JR, Pinto MT, Arsequell G, Cardoso I. Neuroprotection in early stages of Alzheimer's disease is promoted by transthyretin angiogenic properties. ALZHEIMERS RESEARCH & THERAPY 2021; 13:143. [PMID: 34429155 PMCID: PMC8385857 DOI: 10.1186/s13195-021-00883-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
Background While still controversial, it has been demonstrated that vascular defects can precede the onset of other AD hallmarks features, making it an important therapeutic target. Given that the protein transthyretin (TTR) has been established as neuroprotective in AD, here we investigated the influence of TTR in the vasculature. Methods We evaluated the thickness of the basement membrane and the length of brain microvessels, by immunohistochemistry, in AβPPswe/PS1A246E (AD) transgenic mice and non-transgenic mice (NT) bearing one (TTR+/−) or two (TTR+/+) copies of the TTR gene. The angiogenic potential of TTR was evaluated in vitro using the tube formation assay, and in vivo using the chick chorioallantoic membrane (CAM) assay. Results AD transgenic mice with TTR genetic reduction, AD/TTR+/−, exhibited a thicker BM in brain microvessels and decreased vessel length than animals with normal TTR levels, AD/TTR+/+. Further in vivo investigation, using the CAM assay, revealed that TTR is a pro-angiogenic molecule, and the neovessels formed are functional. Also, TTR increased the expression of key angiogenic molecules such as proteins interleukins 6 and 8, angiopoietin 2, and vascular endothelial growth factor, by endothelial cells, in vitro, under tube formation conditions. We showed that while TTR reduction also leads to a thicker BM in NT mice, this effect is more pronounced in AD mice than in NT animals, strengthening the idea that TTR is a neuroprotective protein. We also studied the effect of TTR tetrameric stabilization on BM thickness, showing that AD mice treated with the TTR tetrameric stabilizer iododiflunisal (IDIF) displayed a significant reduction of BM thickness and increased vessel length, when compared to non-treated littermates. Conclusion Our in vivo results demonstrate the involvement of TTR in angiogenesis, particularly as a modulator of vascular alterations occurring in AD. Since TTR is decreased early in AD, its tetrameric stabilization can represent a therapeutic avenue for the early treatment of AD through the maintenance of the vascular structure. Supplementary Information The online version contains supplementary material available at 10.1186/s13195-021-00883-8.
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Affiliation(s)
- Tiago Gião
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), 4050-013, Porto, Portugal
| | - Joana Saavedra
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal
| | - José Ricardo Vieira
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Marta Teixeira Pinto
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal.,IPATIMUP - Instituto de Patologia e Imunologia Molecular, Universidade do Porto, Rua Júlio Amaral de Carvalho,45-, 4200-135, Porto, Portugal
| | - Gemma Arsequell
- Institut de Química Avançada de Catalunya (I.Q.A.C.-C.S.I.C.), 08034, Barcelona, Spain
| | - Isabel Cardoso
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal. .,IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Rua Alfredo Allen 208, 4200-135, Porto, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), 4050-013, Porto, Portugal.
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Cehofski LJ, Kruse A, Alsing AN, Nielsen JE, Pedersen S, Kirkeby S, Honoré B, Vorum H. Intravitreal bevacizumab upregulates transthyretin in experimental branch retinal vein occlusion. Mol Vis 2018; 24:759-766. [PMID: 30581282 PMCID: PMC6279196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/24/2018] [Indexed: 10/28/2022] Open
Abstract
Purpose To identify retinal protein changes that mediate beneficial effects of intravitreal bevacizumab in experimental branch retinal vein occlusion (BRVO). Methods In six Danish Landrace pigs, BRVO was induced with argon laser in both eyes. After BRVO was induced, the right eye of each animal was given an intravitreal injection of bevacizumab while the left eye was treated with saline water. The retinas were collected 15 days after BRVO, and differentially expressed proteins were analyzed with tandem mass tags-based mass spectrometry. Validation of statistically significantly changed proteins was performed with immunohistochemistry and western blotting. Results Fluorescein angiography showed no recanalization of the occluded vessels. A total of 4,013 proteins were successfully identified and quantified. Nine proteins were statistically significantly changed following bevacizumab intervention. In experimental BRVO, bevacizumab treatment resulted in upregulation of transthyretin (TTR) and pantothenate kinase 3. Bevacizumab downregulated protocadherin 7, protein FAM192A, and ATP synthase protein 8. Immunohistochemistry revealed that TTR was highly abundant in the choroid following bevacizumab intervention. Conclusions Bevacizumab intervention in experimental BRVO resulted in an increased level of TTR. This is the second study in which we showed an increased retinal level of TTR following anti-vascular endothelial growth factor (VEGF) intervention in experimental BRVO. We hypothesize that there is an interaction between TTR and VEGF and that bevacizumab may exert a beneficial effect on the retina by upregulating TTR.
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Affiliation(s)
- Lasse Jørgensen Cehofski
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark,Biomedical Research Laboratory, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anders Kruse
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
| | - Alexander Nørgård Alsing
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark,Biomedical Research Laboratory, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Shona Pedersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark,Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Svend Kirkeby
- Department of Odontology, School of Dentistry, University of Copenhagen, Copenhagen, Denmark
| | - Bent Honoré
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Henrik Vorum
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Rousseau A, Terrada C, Touhami S, Barreau E, Rothschild PR, Valleix S, Benoudiba F, Errera MH, Cauquil C, Guiochon-Mantel A, Adams D, Labetoulle M. Angiographic Signatures of the Predominant Form of Familial Transthyretin Amyloidosis (Val30Met Mutation). Am J Ophthalmol 2018; 192:169-177. [PMID: 29859145 DOI: 10.1016/j.ajo.2018.05.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE To describe abnormalities in choroidal and retinal vasculature associated with Val30Met familial transthyretin amyloidosis (V30M-FTA) using fluorescein and indocyanine green (ICG) angiography. DESIGN Prospective, cross-sectional study. METHODS This study was conducted at the French National Reference Center for FTA. We included 18 consecutive genetically confirmed V30M-FTA patients (36 eyes) who underwent complete neurologic examination, including staging with polyneuropathy disability (PND) score, and complete ophthalmic evaluation, including staging of intraocular amyloid deposits and fluorescein and ICG angiograms (ICG-A). The grading of choroidal and retinal angiopathy, and their association with neurologic functional impairment, were the main outcome measures. RESULTS Eleven men and 7 women, mean age 61.6 ± 12.1 years, were included. Retinal amyloid angiopathy (RAA) was detected in 24 eyes (92%) of 13 patients, with microaneurysms, retinal hemorrhages, and retinal ischemia of variable extent. Three patients (5 eyes) had neovascular glaucoma and 2 (2 eyes) had preretinal neovascularization. ICG-A indicated choroidal amyloid angiopathy (CAA) in all patients, with 3 distinct patterns-diffuse (9/18 patients), focal (5/18 patients), or punctiform (4/18 patients)-based on the extent of late hypercyanescence along the choroidal arteries. PND scores were significantly higher in patients with diffuse CAA (firework pattern) compared to those with limited CAA (focal and punctiform patterns) (2.89 vs 1.78, P = .045). CONCLUSION RAA is a frequent and severe complication of V30M-FTA that may lead to anterior and posterior segment neovascularization. CAA was detected in all patients, with a late hypercyanescent delineation of the choroidal arterial vasculature, which was more extensive with increased disease severity.
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Schänzer A, Kimmich C, Röcken C, Haverkamp T, Weidner I, Acker T, Krämer HH. A woman with a rare p.Glu74Gly transthyretin mutation presenting exclusively with a rapidly progressive neuropathy: a case report. J Med Case Rep 2014; 8:403. [PMID: 25471118 PMCID: PMC4289209 DOI: 10.1186/1752-1947-8-403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/06/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Familial amyloid polyneuropathy is a rare autosomal dominant disorder caused by mutations in the transthyretin gene, TTR. Diagnosis can be challenging, especially if other family members are not affected or an obvious systemic involvement is lacking. The patients are often misdiagnosed, leading to a delay in the initiation of therapy. Case presentation A 35-year-old woman of Turkish origin presented to our outpatient clinic with severe polyneuropathy associated with distally pronounced tetraparesis and hypesthesia of 2 to 3 years’ duration. In addition, small nerve fiber involvement with impaired detection of cold temperatures and tingling pain in the lower legs was reported. She did not complain of autonomic dysfunction or visual disturbance. Her family history was empty regarding neuromuscular disorders. The routine diagnostic work-up was unremarkable. A sural nerve biopsy disclosed amyloid deposits, which led to the identification of a rare heterozygous transthyretin mutation (p.Glu74Gly; old classification: p.Glu54Gly). Conclusions Few cases with this very heterozygous mutation can be found in the literature. In contrast to the case of our patient, all of the previously described patients in the literature presented with additional severe autonomic symptoms, involvement of the eyes and a positive family history. In this case report, we emphasize that, in patients with progressive neuropathy with small fiber involvement, an amyloid neuropathy should be considered in the differential diagnosis, even if the family history is empty and other organs are not affected.
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Affiliation(s)
- Anne Schänzer
- Institute of Neuropathology, Justus Liebig University, Arndstrasse 16, 35392 Giessen, Germany.
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Macular and optic disc edema and retinal vascular leakage in familial amyloid polyneuropathy with a transthyretin Val30Met mutation: a case report. J Med Case Rep 2014; 8:327. [PMID: 25282612 PMCID: PMC4190594 DOI: 10.1186/1752-1947-8-327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 08/15/2014] [Indexed: 11/21/2022] Open
Abstract
Introduction Familial amyloid polyneuropathy is a group of autosomal dominant disorders characterized by extracellular amyloid deposition in several target organs. This paper aims to report an unusual manifestation of retinal vascular leakage including optic disc and macular edema in a patient with familial amyloid polyneuropathy. Case presentation A 37-year-old Portuguese Caucasian man with Val30Met transthyretin-related familial amyloid polyneuropathy presented with rapidly progressing visual loss in his left eye. He had undergone liver transplantation at the age of 30 with neurologic stabilization. Fundoscopy and fluorescein angiogram revealed optic disc and macular edema as well as vessel wall staining with leakage in the posterior pole and mid-periphery, without vitreous opacities. A diagnostic work-up for infectious, autoimmune and neoplasic conditions was negative. Systemic immunosuppression was increased but without improvement. Sustained resolution of macular edema was observed after intravitreal injection of dexamethasone implant and laser panretinal photocoagulation. Conclusions To the best of our knowledge, this is the first report of a rare ocular manifestation of familial amyloid polyneuropathy which represents a new therapeutic challenge. Intravitreal injection of sustained release dexamethasone implant and panretinal photocoagulation may be an effective eye-saving therapeutic approach.
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Zhang AM, Wang H, Sun P, Hu QX, He Y, Yao YG. Mutation p.G83R in the transthyretin gene is associated with hereditary vitreous amyloidosis in Han Chinese families. Mol Vis 2013; 19:1631-8. [PMID: 23901247 PMCID: PMC3724954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 07/22/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hereditary vitreous amyloidosis (HVA) is a genetic ophthalmological disorder. The purpose of this study was to investigate whether a mutation in the transthyretin (TTR) gene is associated with HVA in Han Chinese families. METHODS We performed clinical evaluation of three Han Chinese families with HVA and sequenced the entire exon of the TTR gene in probands and normal individuals from the families. The identified mutation was further genotyped in 196 unrelated healthy controls. Evolutionary conservation analysis and structural prediction were used to infer the potential pathogenicity of the mutation. RESULTS Clinical penetrance of HVA varied in the three families (11/30 in Family A, 8/83 in Family B, and 7/47 in Family C). A comprehensive medical examination of the patients showed no signs of abnormality except ophthalmologic symptoms, in which floccular turbidity and high echo in both vitreous bodies were observed in all probands. Further histochemical examination of the vitrectomy specimen with Congo red staining identified amyloid deposits. A heterozygous mutation c.307G>C (p.G83R) in exon 3 of the TTR gene was identified in all patients, but not in some unaffected family members. Screening of 196 unrelated normal controls revealed no presence of this mutation. This mutation changed the highly conserved glycine to arginine in the 83(rd) position and altered the tertiary structure of the TTR protein. CONCLUSIONS Mutation p.G83R in the TTR protein is associated with HVA in Chinese families. The seemingly specific distribution of this mutation in Han Chinese may be used for clinical diagnosis.
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Affiliation(s)
- A-Mei Zhang
- Key Laboratory of Animal Models and Human Disease Mechanisms of Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Kunming, Yunnan, China
| | - Hui Wang
- Kunming Aier Eye Hospital, Kunming, Yunnan, China
| | - Peng Sun
- Kunming Aier Eye Hospital, Kunming, Yunnan, China
| | - Qiu-Xiang Hu
- Key Laboratory of Animal Models and Human Disease Mechanisms of Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Kunming, Yunnan, China,University of Chinese Academy of Sciences, Beijing, China
| | - Yuqing He
- Kunming Aier Eye Hospital, Kunming, Yunnan, China
| | - Yong-Gang Yao
- Key Laboratory of Animal Models and Human Disease Mechanisms of Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Kunming, Yunnan, China
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Zou X, Dong F, Zhang S, Tian R, Sui R. Transthyretin Ala36Pro mutation in a Chinese pedigree of familial transthyretin amyloidosis with elevated vitreous and serum vascular endothelial growth factor. Exp Eye Res 2013; 110:44-9. [PMID: 23438977 DOI: 10.1016/j.exer.2013.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 01/05/2013] [Accepted: 02/04/2013] [Indexed: 01/22/2023]
Abstract
The familial transthyretin (TTR) amyloidosis (FTA) demonstrates variable penetrance of clinical features associated with mutations in the plasma thyroid hormone-binding protein TTR gene. The purpose of this study was to assess the ocular features, to analyze vitreous and serum vascular endothelial growth factor (VEGF) levels, and to identify the genetic defect in a Chinese family with TTR FTA. The pedigree of interest was a three-generation family with eleven members. The primary ocular signs were vitreous opacities, beginning from the third or fourth decade, accompanied by retinal vasculitis, hemorrhages, and widespread pinpoint deposits in the peripheral retina. Two patients underwent vitrectomy with marked improvement of visual acuity postoperatively. Vitreous and serum samples for VEGF were analyzed with an enzyme-linked immunosorbent assay (ELISA). Forty-eight healthy adult volunteers were enrolled as a control group for the analysis of serum VEGF. Eight subjects who underwent vitrectomy for a macular epiretinal membrane or macular hole were enrolled as control for the analysis of vitreous VEGF. Both serum and vitreous VEGF levels of patients were raised compared to that of controls. Venous blood was collected from family members and the genomic DNA was extracted. All exons and exon-intron boundaries of the TTR gene were sequenced. A previously-described pathogenic transversion in exon 2 (c.G106C, p.Ala36Pro) was identified. Within this family eight individuals were confirmed as affected. In conclusion, a Chinese family with TTR Ala36Pro associated FTA is characterized by early ocular involvement. Widespread pinpoint lesions indicate RPE lesions caused by TTR deposition. FTA is associated with increased VEGF levels, both in serum and vitreous.
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Affiliation(s)
- Xuan Zou
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan Road, Dongcheng District, Beijing 100710, China
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Sandhu R, Westcott M, Pavesio C, Rowczenio DM, Gilbertson JA, Gillmore JD, Gibbs SDJ. Retinal microangiopathy as an initial manifestation of familial amyloid cardiomyopathy associated with transthyretin e89k mutation. Retin Cases Brief Rep 2013; 7:271-275. [PMID: 25391122 DOI: 10.1097/icb.0b013e31828eefa2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To report a rare case of transthyretin (TTR) familial amyloid cardiomyopathy with retinal microangiopathy and vitreous amyloid as the initial manifestation. METHODS A 54-year-old woman presented with bilateral retinal microangiopathy, presumed idiopathic retinal vasculitis. She subsequently developed retinal ischemia associated vitreous hemorrhage and was treated with panretinal laser photocoagulation. Clinical eye signs remained stable for 6 years with the absence of overt inflammation. However, the patient developed chest pain and atrial flutter and underwent echocardiography, cardiac magnetic resonance imaging, and Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy to investigate possible cardiac amyloidosis. Sequencing of the TTR gene was conducted and a rectal biopsy performed for tissue diagnosis. A full neurologic screen was also conducted. RESULTS Cardiac investigations were highly suggestive of an amyloid cardiomyopathy. The rectal biopsy stained positive for Congo red with demonstration of apple green birefringence, confirming amyloid, and immunostaining confirmed the TTR subtype. Gene sequencing revealed heterozygous TTR mutation encoding E89K variant. No significant neuropathy could be detected. CONCLUSION Amyloid should be considered as a masquerade diagnosis in cases of retinal microangiopathy, especially in the absence of inflammation. Liaising with physicians for systemic evaluation and TTR gene sequencing is essential for early diagnosis and management of this rare condition.
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Affiliation(s)
- Ranjit Sandhu
- *Medical Retina Service, Moorfields Eye Hospital, London, United Kingdom; and †National Amyloidosis Centre, UCL Division of Medicine, Royal Free Hospital, London, United Kingdom
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Beirão NM, Miranda V, Beirão I, Costa PP, Torres P. The use of intravitreal ranibizumab to treat neovascular glaucoma because of retinal amyloid angiopathy in familial amyloidosis transthyretin v30m related. Retin Cases Brief Rep 2013; 7:114-116. [PMID: 25390540 DOI: 10.1097/icb.0b013e3182681259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE The purpose of this study to report a patient with amyloidotic angiopathy and neovascular glaucoma who was treated with intravitreal injection of ranibizumab followed by laser photocoagulation. METHODS A 52-year-old liver-transplanted woman with familial amyloidotic polyneuropathy presented with unilateral rubeosis iridis and neovascular glaucoma. A complete ocular examination and fluorescein and indocyanine green angiography were performed. RESULTS Best-corrected visual acuity before injection was 0.05 (Snellen) in the left eye, and intraocular pressure was 42 mmHg. Fluorescein angiography showed vascular occlusion in the retinal periphery, focal staining of vessels, and microaneurysms. Indocyanine green angiography showed hyperfluorescent spots alongside the choroidal veins. Two days after receiving intravitreal injection of ranibizumab, the clinical picture regressed. The diagnosis of retinal amyloid angiopathy was made, and a peripheral retinal laser photocoagulation was done. The final best-corrected visual acuity after 2 years of follow-up was 0.4 (Snellen) in the left eye. CONCLUSION Intravitreal injections of ranibizumab should be evaluated for a potential role on the treatment of amyloid angiopathy neovascular glaucoma. Careful retinal periphery examination should be included in the ophthalmologic examination of all familial amyloidotic polyneuropathy patients.
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Affiliation(s)
- Nuno M Beirão
- *Serviço de Oftalmologia, and †Unidade Clínica de Paramiloidose, Hospital de Santo António, Porto, Portugal ‡UMIB, ICBAS, Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal §INSA Dr. Ricardo Jorge, Porto, Portugal
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Conformational diseases: looking into the eyes. Brain Res Bull 2010; 81:12-24. [PMID: 19808079 DOI: 10.1016/j.brainresbull.2009.09.015] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 09/11/2009] [Accepted: 09/29/2009] [Indexed: 01/09/2023]
Abstract
Conformational diseases, a general term comprising more than 40 disorders are caused by the accumulation of unfolded or misfolded proteins. Improper protein folding (misfolding) as well as accrual of unfolded proteins can lead to the formation of disordered (amorphous) or ordered (amyloid fibril) aggregates. The gradual accumulation of protein aggregates and the acceleration of their formation by stress explain the characteristic late or episodic onset of the diseases. The best studied in this group are neurodegenerative diseases and amyloidosis accompanied by the deposition of a specific aggregation-prone proteins or protein fragments and formation of insoluble fibrils. Amyloidogenic protein accumulation often occurs in the brain tissues, e.g. in Alzheimer's disease with the deposition of amyloid-beta and Tau, in scrapie and bovine spongiform encephalopathy with the accumulation of prion protein, in Parkinson's disease with the deposition of alpha-synuclein. Other examples of amyloid proteins are transthyretin, immunoglobulin light chain, gelsolin, etc. In addition to the brain, the accumulation of unfolded or misfolded proteins leading to pathology takes place in a wide variety of organs and tissues, including different parts of the eye. The best studied ocular conformational diseases are cataract in the lens and retinitis pigmentosa in the retina, but accumulation of misfolded proteins also occurs in other parts of the eye causing various disorders. Furthermore, ocular manifestation of systemic amyloidosis often causes the deposition of amyloidogenic proteins in different ocular tissues. Here we present the data regarding naturally unfolded and misfolded proteins in eye tissues, their structure-function relationships, and molecular mechanisms underlying their involvement in diseases. We also summarize the etiology of ocular conformational diseases and discuss approaches to their treatment.
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