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Reis LM, Maheshwari M, Capasso J, Atilla H, Dudakova L, Thompson S, Zitano L, Lay-Son G, Lowry RB, Black J, Lee J, Shue A, Kremlikova Pourova R, Vaneckova M, Skalicka P, Jedlickova J, Trkova M, Williams B, Richard G, Bachman K, Seeley AH, Costakos D, Glaser TM, Levin AV, Liskova P, Murray JC, Semina EV. Axenfeld-Rieger syndrome: more than meets the eye. J Med Genet 2023; 60:368-379. [PMID: 35882526 PMCID: PMC9912354 DOI: 10.1136/jmg-2022-108646] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Axenfeld-Rieger syndrome (ARS) is characterised by typical anterior segment anomalies, with or without systemic features. The discovery of causative genes identified ARS subtypes with distinct phenotypes, but our understanding is incomplete, complicated by the rarity of the condition. METHODS Genetic and phenotypic characterisation of the largest reported ARS cohort through comprehensive genetic and clinical data analyses. RESULTS 128 individuals with causative variants in PITX2 or FOXC1, including 81 new cases, were investigated. Ocular anomalies showed significant overlap but with broader variability and earlier onset of glaucoma for FOXC1-related ARS. Systemic anomalies were seen in all individuals with PITX2-related ARS and the majority of those with FOXC1-related ARS. PITX2-related ARS demonstrated typical umbilical anomalies and dental microdontia/hypodontia/oligodontia, along with a novel high rate of Meckel diverticulum. FOXC1-related ARS exhibited characteristic hearing loss and congenital heart defects as well as previously unrecognised phenotypes of dental enamel hypoplasia and/or crowding, a range of skeletal and joint anomalies, hypotonia/early delay and feeding disorders with structural oesophageal anomalies in some. Brain imaging revealed highly penetrant white matter hyperintensities, colpocephaly/ventriculomegaly and frequent arachnoid cysts. The expanded phenotype of FOXC1-related ARS identified here was found to fully overlap features of De Hauwere syndrome. The results were used to generate gene-specific management plans for the two types of ARS. CONCLUSION Since clinical features of ARS vary significantly based on the affected gene, it is critical that families are provided with a gene-specific diagnosis, PITX2-related ARS or FOXC1-related ARS. De Hauwere syndrome is proposed to be a FOXC1opathy.
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Affiliation(s)
- Linda M Reis
- Department of Pediatrics and Children's Research Institute, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohit Maheshwari
- Department of Pediatric Radiology, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jenina Capasso
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children's Hospital and University of Rochester, Rochester, New York, USA
| | - Huban Atilla
- Department of Ophthalmology, School of Medicine, Ankara University, Ankara, Turkey
| | - Lubica Dudakova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Samuel Thompson
- Department of Pediatrics and Children's Research Institute, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Lia Zitano
- Department of Medical Genetics, Spectrum Health, Grand Rapids, Michigan, USA
| | - Guillermo Lay-Son
- Unidad de Genética, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - R Brian Lowry
- Department of Clinical Genetics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jennifer Black
- Center for Development, Behavior, and Genetics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Joseph Lee
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ann Shue
- Byers Eye Institute, Department of Ophthalmology, Stanford University and Stanford Children's Health, Stanford, California, USA
| | - Radka Kremlikova Pourova
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Pavlina Skalicka
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jana Jedlickova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Marie Trkova
- Gennet, Centre for Fetal Medicine and Reproductive Genetics, Prague, Czech Republic
| | | | | | - Kristine Bachman
- Department of Pediatrics, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Andrea H Seeley
- Department of Pediatrics, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Deborah Costakos
- Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas M Glaser
- Department of Cell Biology and Human Anatomy, UC-Davis School of Medicine, Davis, California, USA
| | - Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children's Hospital and University of Rochester, Rochester, New York, USA
| | - Petra Liskova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jeffrey C Murray
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Elena V Semina
- Department of Pediatrics and Children's Research Institute, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin, USA
- Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Reis LM, Sorokina EA, Dudakova L, Moravikova J, Skalicka P, Malinka F, Seese SE, Thompson S, Bardakjian T, Capasso J, Allen W, Glaser T, Levin AV, Schneider A, Khan A, Liskova P, Semina EV. Comprehensive phenotypic and functional analysis of dominant and recessive FOXE3 alleles in ocular developmental disorders. Hum Mol Genet 2021; 30:1591-1606. [PMID: 34046667 PMCID: PMC8369840 DOI: 10.1093/hmg/ddab142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
The forkhead transcription factor FOXE3 is critical for vertebrate eye development. Recessive and dominant variants cause human ocular disease but the full range of phenotypes and mechanisms of action for the two classes of variants are unknown. We identified FOXE3 variants in individuals with congenital eye malformations and carried out in vitro functional analysis on selected alleles. Sixteen new recessive and dominant families, including six novel variants, were identified. Analysis of new and previously reported genetic and clinical data demonstrated a broad phenotypic range with an overlap between recessive and dominant disease. Most families with recessive alleles, composed of truncating and forkhead-domain missense variants, had severe corneal opacity (90%; sclerocornea in 47%), aphakia (83%) and microphthalmia (80%), but some had milder features including isolated cataract. The phenotype was most variable for recessive missense variants, suggesting that the functional consequences may be highly dependent on the type of amino acid substitution and its position. When assessed, aniridia or iris hypoplasia were noted in 89% and optic nerve anomalies in 60% of recessive cases, indicating that these defects are also common and may be underrecognized. In dominant pedigrees, caused by extension variants, normal eye size (96%), cataracts (99%) and variable anterior segment anomalies were seen in most, but some individuals had microphthalmia, aphakia or sclerocornea, more typical of recessive disease. Functional studies identified variable effects on the protein stability, DNA binding, nuclear localization and transcriptional activity for recessive FOXE3 variants, whereas dominant alleles showed severe impairment in all areas and dominant-negative characteristics.
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Affiliation(s)
- Linda M Reis
- Department of Pediatrics and Children's Research Institute at the Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
| | - Elena A Sorokina
- Department of Pediatrics and Children's Research Institute at the Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
| | - Lubica Dudakova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jana Moravikova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavlina Skalicka
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Frantisek Malinka
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Department of Computer Science, Czech Technical University in Prague, Prague, Czech Republic
| | - Sarah E Seese
- Department of Pediatrics and Children's Research Institute at the Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
| | - Samuel Thompson
- Department of Pediatrics and Children's Research Institute at the Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
| | - Tanya Bardakjian
- Department of Pediatrics, Albert Einstein Medical Center, Philadelphia, PA 19141, USA
| | - Jenina Capasso
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Pediatric Genetics, Golisano Children's Hospital, University of Rochester, Rochester, NY 14534 USA
| | - William Allen
- Fullerton Genetics Center, Mission Hospitals, HCA, Asheville, NC, 28803 USA
| | - Tom Glaser
- Cell Biology and Human Anatomy Department, UC-Davis School of Medicine, Davis, CA 95616, USA
| | - Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Pediatric Genetics, Golisano Children's Hospital, University of Rochester, Rochester, NY 14534 USA
| | - Adele Schneider
- Department of Pediatrics, Albert Einstein Medical Center, Philadelphia, PA 19141, USA
| | - Ayesha Khan
- Pediatric Ophthalmology & Strabismus Unit, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan.,Consultant Pediatric Ophthalmologist, Al Jalila Children's Specialty Hospital, United Arab Emirates
| | - Petra Liskova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Elena V Semina
- Department of Pediatrics and Children's Research Institute at the Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA.,Departments of Ophthalmology and Cell Biology, Neurobiology and Anatomy at the Medical College of Wisconsin, Milwaukee, WI 53226, USA
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