Choroideremia: Update On Clinical Features And Emerging Treatments

Fluorescence Lifetime Imaging Ophthalmoscopy, Vision, and Chorioretinal Asymmetries in Aging and Age-Related Macular Degeneration: ALSTAR2

Purpose

Eyes with age-related macular degeneration (AMD) and some healthy aged eyes exhibit risk-indicating delays in rod-mediated dark adaptation (RMDA) and prolonged long spectral channel (LSC) lifetimes by fluorescence lifetime imaging ophthalmoscopy (FLIO) in the Early Treatment Diabetic Retinopathy Study (ETDRS) outer ring, especially nasally. To learn FLIO's potential for AMD detection, we correlate FLIO to RMDA.

Methods

The ALSTAR2 follow-up cohort underwent FLIO, color fundus photography, two-wavelength autofluorescence (for macular pigment optical density [MPOD]), visual function testing, including RMDA (rod intercept time [RIT]). AMD was staged by the Age-Related Eye Disease Study (AREDS) 9-step at baseline and follow-up. In pseudophakic eyes with high-quality FLIO, mean intensity maps and meridian plots were created. Vision data were analyzed using linear regression and Spearman's r.

Results

Of 155 eyes (155 participants [75 ± 5.0 years; 60.7% female participants]), 67 eyes were healthy, 38 had early (e)AMD, and 50 had intermediate (i)AMD (P = 0.02). LSC lifetimes were longest in iAMD in all ETDRS regions (P < 0.01) and short spectral channel (SSC) lifetimes in inner and outer rings (P < 0.01). The LSC pattern manifested in 65 of 88 AMD eyes and 30 of 67 healthy eyes. Lifetimes were longest on the nasal meridian and shortest on temporal. LSC lifetimes in the inner and outer rings correlated strongly with RIT (r = 0.68). A stable subgroup had short LSC lifetimes and short RIT. SSC correlated weakly with MPOD.

Conclusions

Prolonged lifetimes in AMD exhibit spatial asymmetry, suggesting mechanisms beyond retinal cells and including choroid. Lifetimes correlate with delayed RMDA, potentially indicating risk for AMD onset and early progression. Further research into SSC signal sources is warranted.

Suppressor tRNA in gene therapy

Suppressor tRNAs are engineered or naturally occurring transfer RNA molecules that have shown promise in gene therapy for diseases caused by nonsense mutations, which result in premature termination codons (PTCs) in coding sequence, leading to truncated, often nonfunctional proteins. Suppressor tRNAs can recognize and pair with these PTCs, allowing the ribosome to continue translation and produce a full-length protein. This review introduces the mechanism and development of suppressor tRNAs, compares suppressor tRNAs with other readthrough therapies, discusses their potential for clinical therapy, limitations, and obstacles. We also summarize the applications of suppressor tRNAs in both in vitro and in vivo, offering new insights into the research and treatment of nonsense mutation diseases.

Extent and Topography of Subretinal Drusenoid Deposits Associate With Rod-Mediated Vision in Aging and AMD: ALSTAR2 Baseline

Purpose

In AMD, rod-mediated dark adaptation (RMDA) at 5° eccentricity is slower in eyes with subretinal drusenoid deposits (SDDs) than in eyes without. Here we quantified SDD burden using supervised deep learning for comparison to vision and photoreceptor topography.

Methods

In persons ≥60 years from the Alabama Study on Early Age-Related Macular Degeneration 2, normal, early AMD, and intermediate AMD eyes were classified by the AREDS nine-step system. A convolutional neural network was trained on 55°-wide near-infrared reflectance images for SDD segmentation. Trained graders annotated ground truth (SDD yes/no). Predicted and true datasets agreed (Dice coefficient, 0.92). Inference was manually proofread using optical coherence tomography. The mean SDD area (mm2) was compared among diagnostic groups (linear regression) and to vision (age-adjusted Spearman correlations). Fundus autofluorescence images were used to mask large vessels in SDD maps.

Results

In 428 eyes of 428 persons (normal, 218; early AMD, 120; intermediate AMD, 90), the mean SDD area differed by AMD severity (P < 0.0001): 0.16 ± 0.87 (normal), 2.48 ± 11.23 (early AMD), 11.97 ± 13.33 (intermediate AMD). Greater SDD area was associated with worse RMDA (r = 0.27; P < 0.0001), mesopic (r = -0.13; P = 0.02) and scotopic sensitivity (r = -0.17; P < 0.001). SDD topography peaked at 5° superior, extended beyond the Early Treatment of Diabetic Retinopathy Study grid and optic nerve, then decreased.

Conclusions

SDD area is associated with degraded rod-mediated vision. RMDA 5° (superior retina) probes where SDD is maximal, closer to the foveal center than the rod peak at 3 to 6 mm (10.4°-20.8°) superior and the further eccentric peak of rod:cone ratio. Topographic data imply that factors in addition to rod density influence SDD formation.

Contiguous Gene Syndromes and Hearing Loss: A Clinical Report of Xq21 Deletion and Comprehensive Literature Review

Given the crucial role of the personalized management and treatment of hearing loss (HL), etiological investigations are performed early on, and genetic analysis significantly contributes to the determination of most syndromic and nonsyndromic HL cases. Knowing hundreds of syndromic associations with HL, little comprehensive data about HL in genomic disorders due to microdeletion or microduplications of contiguous genes is available. Together with the description of a new patient with a novel 3.7 Mb deletion of the Xq21 critical locus, we propose an unreported literature review about clinical findings in patients and their family members with Xq21 deletion syndrome. We finally propose a comprehensive review of HL in contiguous gene syndromes in order to confirm the role of cytogenomic microarray analysis to investigate the etiology of unexplained HL.

Posterior Polar Annular Choroidal Dystrophy: Genetic Insights and Differential Diagnosis in Inherited Retinal Diseases

Posterior polar annular choroidal dystrophy (PPACD) is a rare ocular disorder and presents as symmetric degeneration of the retinal pigment epithelium (RPE) and the underlying choriocapillaris, encircling the retinal vascular arcades and optic disc. This condition distinctively preserves the foveal region, optic disc, and the outermost regions of the retina. Despite its distinct clinical presentation, due to the infrequency of its occurrence and the limited number of reported cases, the pathophysiology, and the genetic foundations of PPACD are still largely uncharted. This review aims to bridge this knowledge gap by investigating potential genetic contributors to PPACD, assessing current findings, and identifying genes that warrant further study. Emphasis is also placed on the crucial role of multimodal imaging in diagnosing PPACD, highlighting its importance in understanding disease pathophysiology. By analyzing existing case reports and drawing comparisons with similar retinal disorders, this paper endeavors to delineate the possible genetic correlations in PPACD, providing a foundation for future genetic research and the development of targeted diagnostic strategies.

Female carriers of X-linked inherited retinal diseases - Genetics, diagnosis, and potential therapies

Inherited retinal diseases (IRDs) are a group of heterogeneous conditions that cause progressive vision loss, typically due to monogenic mutations. Female carriers of X-linked IRDs have a single copy of the disease-causing gene, and therefore, may exhibit variable clinical signs that vary from near normal retina to severe disease and vision loss. The relationships between individual genetic mutations and disease severity in X-linked carriers requires further study. This review summarises the current literature surrounding the spectrum of disease seen in female carriers of choroideremia and X-linked retinitis pigmentosa. Various classification systems are contrasted to accurately grade retinal disease. Furthermore, genetic mechanisms at the early embryonic stage are explored to potentially explain the variability of disease seen in female carriers. Future research in this area will provide insight into the association between genotype and retinal phenotypes of female carriers, which will guide in the management of these patients. This review acknowledges the importance of identifying which patients may be at high risk of developing severe symptoms, and therefore should be considered for emerging treatments, such as retinal gene therapy.

Gyrate Atrophy of the Choroid and Retina: A Review

Gyrate atrophy (GA) of the choroid and retina is a rare autosomal recessive genetic condition characterized by elevation of the plasma level of the amino acid ornithine due to deficiency of the enzyme ornithine ketoacid aminotransferase. Accumulation of ornithine occurs in various body tissues but leads primarily to characteristic ophthalmic manifestations including myopia, cataract, progressive chorioretinal atrophy, and macular changes. Patients usually present with night blindness that starts in the first decade of life followed by visual field constriction and eventually diminution of the central visual acuity and blindness. The condition has been reported worldwide and its differential diagnosis is broad and includes choroideremia and retinitis pigmentosa. Treatment currently depends on life-long dietary modifications including restriction of the amino acid arginine in diet. This article describes in detail the pathogenesis, clinical features, multimodal imaging findings, and treatment options for GA of the choroid and retina and its complications.

Human MiniPromoters for ocular-rAAV expression in ON bipolar, cone, corneal, endothelial, Müller glial, and PAX6 cells

Small and cell-type restricted promoters are important tools for basic and preclinical research, and clinical delivery of gene therapies. In clinical gene therapy, ophthalmic trials have been leading the field, with over 50% of ocular clinical trials using promoters that restrict expression based on cell type. Here, 19 human DNA MiniPromoters were bioinformatically designed for rAAV, tested by neonatal intravenous delivery in mouse, and successful MiniPromoters went on to be tested by intravitreal, subretinal, intrastromal, and/or intravenous delivery in adult mouse. We present promoter development as an overview for each cell type, but only show results in detail for the recommended MiniPromoters: Ple265 and Ple341 (PCP2) ON bipolar, Ple349 (PDE6H) cone, Ple253 (PITX3) corneal stroma, Ple32 (CLDN5) endothelial cells of the blood-retina barrier, Ple316 (NR2E1) Müller glia, and Ple331 (PAX6) PAX6 positive. Overall, we present a resource of new, redesigned, and improved MiniPromoters for ocular gene therapy that range in size from 784 to 2484 bp, and from weaker, equal, or stronger in strength relative to the ubiquitous control promoter smCBA. All MiniPromoters will be useful for therapies involving small regulatory RNA and DNA, and proteins ranging from 517 to 1084 amino acids, representing 62.9-90.2% of human proteins.

Fluorescence Lifetime Imaging Ophthalmoscopy (FLIO) in Patients with Choroideremia

Purpose

To provide a detailed characterization of choroideremia (CHM) using fluorescence lifetime imaging ophthalmoscopy (FLIO) and to provide a deeper understanding of disease-related changes and progression.

Methods

Twenty-eight eyes of 14 patients with genetically confirmed CHM (mean age, 28 ± 14 years) and 14 age-matched healthy subjects were investigated in this study. FLIO images of a 30° retinal field were collected at the Moran Eye Center using a Heidelberg Engineering FLIO device. FLIO lifetimes were recorded in short spectral channels (SSC; 498-560 nm) and long spectral channels (LSC; 560-720 nm), and mean autofluorescence lifetimes (τm) were calculated. Optical coherence tomography (OCT) scans were recorded for each patient. Three patients were re-imaged after a year.

Results

Patients with CHM exhibit specific FLIO lifetime patterns. Prolonged FLIO lifetimes (around 600-700 ps) were found in the peripheral macula corresponding to atrophy in OCT imaging. In the central macula, τm was unrelated to autofluorescence intensity. Some areas of persistent retinal pigment epithelial islands had prolonged FLIO lifetimes, whereas other areas of hypofluorescence had short FLIO lifetimes. At 1-year follow-up, FLIO lifetimes were significantly prolonged within atrophic areas (P < 0.05).

Conclusions

FLIO shows distinct patterns in patients with CHM, indicating lesions of atrophy and areas of preserved function in the presence or absence of findings in fundus autofluorescence intensity images. FLIO may provide differentiated knowledge about pathophysiology and atrophy progression in CHM compared to conventional imaging modalities.

Translational Relevance

FLIO shows distinctive lifetime patterns that potentially identify areas of function, atrophy, and disease progression in patients with CHM.