The Phenotype of Early-Onset Retinal Degeneration in Persons with RDH12 Mutations

Abstract

purpose. To describe the retinal dystrophy phenotype associated with mutations in RDH12, the gene encoding a retinoid dehydrogenase/reductase expressed in the photoreceptor cells.

methods. Sixteen persons from 12 families with pathogenic RDH12 mutations on both alleles were studied. Retinal phenotypes were characterized by ophthalmic examination, including psychophysical and standardized electrophysiological methods and multifocal electroretinography (mfERG).

results. The retinal disease in persons with RDH12 mutations in the homozygous (p.G127X, p.Q189X, p.Y226C, p.A269GfsX1, and p.L274P) or compound heterozygous state (p.R65X/p.A269GfsX1, p.H151D/p.T155I, p.H151D/p.A269GfsX1) was diagnosed initially as Leber congenital amaurosis (LCA) or early-onset retinitis pigmentosa. These individuals appeared to share a common clinical picture, independent of the type of mutation, characterized by poor, yet useful visual function in early life, followed by progressive decline due to both rod and cone degeneration. Marked pigmentary retinopathy, including bone spicules in the peripheral retina, was present in all persons older than age 6, and pronounced maculopathy was evident in persons older than 7 years. A unique view into the progressive nature of the disorder was achieved by evaluation of seven affected persons from three consanguineous families, all carrying the homozygous p.Y226C mutation.

conclusions. Ophthalmic findings in persons with RDH12 mutations suggest that RDH12 loss-of-function results in a characteristic form of early and progressive rod–cone degeneration distinct from that caused by mutations in other LCA genes. From our data, it seems likely that various clinical designations appropriately describe the diagnosis in these persons, including early-onset retinitis pigmentosa, LCA type II, and childhood retinal dystrophy.

Leber congenital amaurosis (LCA) is a clinically and genetically heterogeneous group of rod–cone or cone–rod dystrophies. Although a few families with autosomal dominant inheritance have been reported, typically the condition is transmitted as an autosomal recessive trait. In clinical practice, LCA is diagnosed when there is a marked visual impairment of very early onset (from birth on), whereas the disease is termed juvenile retinitis pigmentosa (RP) if vision loss is evident during the first 2 years of life. ^{1 2 3} Fundus appearance in persons with LCA may initially be normal, although intraretinal pigment deposits, chorioretinal atrophy, white fundus flecks, macular aplasia, and retinal vessel narrowing have been described. ^{4 5 6} The pathologic basis of the visual impairment is a progressive photoreceptor dystrophy as evidenced by severely diminished or absent rod and cone responses on the electroretinogram (ERG). 

RDH12 encodes a member of the superfamily of short-chain alcohol dehydrogenases/reductases and is expressed predominantly in photoreceptors. ⁷ Enzymes of this group play a critical role in reactions of the visual cycle responsible for the interconversion of vitamin A (all-trans retinal) to 11-cis retinal, the light-absorbing chromophore of rhodopsin and cone opsins. ⁸ Mutations in genes affecting visual cycle function have been found to be associated with various forms of retinal degeneration, including LCA (for a review, see Ref. ⁹ ). Recently, RDH12 mutations have been identified in a number of persons diagnosed with severe early-onset rod–cone dystrophy, including LCA, originating from Europe and the United States. ^{10 11 12}  

In this report, we present detailed analysis of the ocular phenotype of 16 persons from 12 families most likely to be carrying disease-causing mutations of the RDH12 gene, including cross-sectional data from seven persons from three consanguineous families believed to belong to an extended kindred. In this cohort, we found that RDH12 mutations cause an early-onset form of severe retinal dystrophy affecting both rod and cone function and having a phenotype distinct from that resulting from mutations in other known LCA genes. 

Methods

Subjects

Informed consent was obtained from all persons involved in the study or from their legal guardians in accordance with the tenets of the Declaration of Helsinki. Linkage mapping and the positional candidate approach first led to detection of patients with the RDH12 mutation p.Y226C in three families. ¹¹ Subsequently, we identified RDH12 mutations in 22 DNA samples of 1011 unrelated additional patients with retinitis pigmentosa and LCA. ¹² We evaluated the comprehensive clinical records from 12 index cases and 4 affected relatives thereof. Detailed clinical findings of these 16 patients (age, 4–69 years) have not been reported previously. Patients initially received a diagnosis of LCA, early-onset RP, or tapetoretinal degeneration, on the basis of typical symptoms and signs of the disease. 

Clinical Evaluation

Phenotype analysis consisted of clinical ophthalmic examination, Goldmann perimetry, panel D15 color vision testing, dark-adapted final thresholds, Ganzfeld electroretinography, and multifocal electroretinography (mfERG). Ganzfeld electroretinography was recorded according to ISCEV (International Society for Clinical Electrophysiology of Vision) standards ¹³ (Espion E² system and ColorDome Ganzfeld stimulator; Diagnosys UK Ltd., Cambridge, UK) using DTL electrodes. White flashes were used at a standard flash intensity of 2.25 cd-s/m², and for L-cone recordings a single red flash (650 nm) at a flash intensity of 2.25 cd-s/m² was used. MfERG was performed according to the method described by Sutter and Tran ¹⁴ (VERIS System; EDI, San Francisco, CA). 

Results

Persons Studied

Table 1summarizes the RDH12 sequence changes identified in the 16 probands included in this study. ^{11 12} A total of 13 persons in nine families had RDH12 mutations in the homozygous state, whereas 3 persons in the three remaining families were compound heterozygous. Within this group, a range of phenotypic presentations was seen, with many cases of severe, early-onset rod–cone degeneration. In most individuals, initial diagnosis was made in early childhood due to visual field constriction, loss of visual acuity, and, often, night blindness. 

Clinical data of persons with RDH12 mutations are presented in this section and summarized in Table 1 . 

Night Blindness and Photophobia

All 16 patients reported night blindness with variable age of onset, ranging from early infancy to 20 years. Photophobia was reported only by two of the 16 probands (patients 4 and 5; age >30 years). 

Visual Acuity

Visual acuities varied considerably and ranged from 50/100 in the youngest affected individual (proband 13, 4 years old) to light perception in an affected individual 33 years old. Taking into account outside medical records at earlier ages and individual histories of the 16 persons, relatively well-preserved visual acuity in childhood, with values from 10/100 to 50/100, appeared to be a uniform feature in six of seven persons examined at ages 4 to 10 years (patients 1, 7, 8, 14, 15, and 16), and was independent of mutation type. An age-related progressive loss of visual acuity was evident, with values from 10/100 to light perception in persons at ages >20 years. 

Refractive Error

Cycloplegic refractions were determined in 14 of the 16 persons and revealed hyperopia >3 D in 3 persons, emmetropia or mild hyperopia ≤3 D in 10 persons, and myopia in 1 person. 

Visual Fields

Visual fields were constricted symmetrically. A typical example of constriction of primarily affected, yet preserved, visual fields was seen in patient 7 (Fig. 1C)from family III, belonging to the large Austrian kindred carrying the p.Y226C mutation in the homozygous state. Although less longitudinal data were available for visual fields than for visual acuities, progression in the extent of constriction with time was evident. For example, visual fields were diminished to 20° to 40° in patient 7 at 7 years, to 10° in patient 14 at 9 years, and to 5° in patient 8 at 9 years of age. Most of the patients showed constrictions to <5° at ages >20 years. Visual fields of the seven Austrian patients, all originating from the same region and carrying the same mutation, further support this conclusion (data not shown). 

Color Vision

Panel D15 color vision testing revealed preserved color vision in young probands. In patient 7 (family III; Fig. 1D ) and patient 13 (family IX), aged 7 and 4 years, respectively, a saturated form of the test showed near normal results or only slight changes of the tritan axis. In a 9-year-old individual (patient 14, family X), slight abnormalities of the tritan axis were seen, whereas in a 20-year-old proband (patient 10, family VI) deficiencies in color vision were demonstrated (data not shown). In persons >20 years old, testing was either not possible or revealed massive color vision disturbances. 

ERG Recordings

The ERGs available for three young persons (patients 7, 13, and 14) demonstrated a diminished yet still preserved rod and cone function at ages 3, 7, and 9 years, respectively. Both rod and cone ERGs were undetectable in 12 persons between 20 and 69 years of age at the time of recording, including the grandfather of patient 7. No ERG data are available for patient 15, a 70-year-old woman. 

Figure 1Ashows the ERG responses of patient 7 carrying the p.Y226C mutation in the homozygous state. Rod and rod–cone responses were decreased but recordable. To demonstrate further the preserved central cone function, we recorded multifocal ERGs in patient 7 and found cone responses for all eccentricities, with amplitude reduction and increased implicit times of cone potentials (Fig. 1B) . Foveal responses were relatively more affected than those of more eccentric rings, possibly reflecting the later development of areolar macular atrophy observed in most of the persons with the p.Y226C mutation. 

Retinal and Macular Findings

In most cases, some form of pigment retinopathy was present, ranging from mild RPE atrophy and midperipheral hyperpigmentation to marked chorioretinopathy with dense hyperpigmentation. Bone spicules were present in 15 of 16 persons carrying two RDH12 mutations. Even in young persons, mild hyperpigmentation could be observed (Fig. 2A , patient 7, age 7). The presence of more pronounced fundal changes in older persons is exemplified by the fundus of patient 6 (p.Y226C, homozygous) of family III (Fig. 2E) . In patient 8, carrying the p.A269GfsX1 mutation in the homozygous state, a secondary vasoproliferative process with Coats-like appearance was present in the right eye. In patient 9 who was homozygous for p.Q189X, diffuse choroidal atrophy was present (Fig. 2F) . 

Physiological macular reflexes were found in only one affected individual (age 4), whereas various stages of maculopathy were noted in 13 of the 16 patients studied. In two persons, no detailed description of macular changes was available. An areolar form of bilateral macular atrophy was frequently observed (Figs. 2B 2C 2D 2E 2F)and consistently seen in members of the three Austrian families with the p.Y226C mutation. Macular changes were mild only in the youngest affected individual from these families (Fig 2 , age 7). In patient 14 (9 years old), the optic disc appeared normal, whereas various degrees of optic nerve head atrophy were present in all affected persons >10 years old. Retinal vessel attenuation ranged from mild to severe throughout the affected persons in our series. 

Cataracts: Anterior Segment

In two young affected persons (patient 13, 4 years old; patient 14, 14 years old), no cataract was observed, whereas in another young person (patient 7, 7 years old) mild subcapsular changes were noted. No clinical details were available for one patient, whereas in the remaining 12 probands with disease-causing RDH12 mutations, all >20 years old, substantial cataract was present, ranging from cortical changes in a few cases to posterior subcapsular cataracts in most of the subjects. In 5 of these 24 eyes, cataract extraction had been performed. Keratoconus was not present in any of the affected persons. 

Discussion

This report presents a comprehensive and comparative clinical description of the ocular phenotype of a cohort of 16 persons with RDH12 mutations. Each patient presented with an early-onset type of severe retinal dystrophy affecting both rod and cone function that was diagnosed as LCA in most cases. They shared a common clinical picture characterized by poor, yet useful visual function in early life, followed by progressive decline of visual function due to both rod and cone degeneration. This conclusion is supported both by the cross-sectional data of our study, and the evaluation of affected persons of different ages from three consanguineous families carrying the p.Y226C mutation, which provides a unique view into the progressive nature of the disorder. 

From our data, it seems that various clinical designations might be given as the diagnosis in affected persons with RDH12 mutations, including early-onset RP, LCA type II, or early-childhood retinal degeneration. At young ages (4–6 years), the patients had best visual acuities in the range of 40 to 50/100, and visual fields were relatively well preserved. Residual rod and cone ERG responses were recordable, with preferential preservation of cone function documented by use of multifocal ERG recordings and panel D15 color testing in a 7-year-old child homozygous for the p.Y226C mutation. Most affected persons showed an absence of photophobia, with mild or absent hyperopia or even myopia. Marked pigmentary retinopathy, including bone spicules in the peripheral retina, was present in persons older than age 6, and pronounced maculopathy was evident at ages older than 7 years. Several persons also exhibited posterior subcapsular cataract. 

Phenotypic trends have been noted for other LCA genes, including RPE65, GUCY2D, AIPL1, CRB1, CRX, and RPGRIP1. ^{15 16 17} Our current data suggest that the clinical course in persons with RDH12 mutations may be most similar to—yet clearly distinguishable from—that reported for persons with RPE65 mutations. ^{18 19 20} Similarities include preservation of visual acuity, peripheral visual fields, and ERG responses at young ages, as well as absence of photophobia, and mild or absent hyperopia. Differences include the presence of dense bone spicule pigmentation in the peripheral retina, as well as maculopathy at ages older than 7 years that is more pronounced than with RPE65 mutations. In addition, persons with RDH12 mutations retain a relatively higher level of early rod–cone function compared with persons with RPE65 mutations who have nonrecordable ERG responses under scotopic conditions and residual photopic responses only at very young ages. ¹⁹ Furthermore, posterior subcapsular cataract appears to be more common in persons with RDH12 mutations than in those with RPE65 mutations. 

The ocular phenotypes of persons affected by mutations in GUCY2D, AIPL1, CRB1, CRX, and RPGRIP1 appeared to differ from that associated with mutations in RDH12 in our patient cohort. GUCY2D mutations cause a severe, congenital phenotype, with pronounced decrease in visual acuity, constriction of visual fields, and nonrecordable ERGs at the earliest age measured. Early cataract, peripheral hyperpigmentation, and maculopathy are usually not seen. ^{20 21} Persons with AIPL1 mutations also have undetectable ERGs at young ages, presumably due to developmental anomalies and/or photoreceptor cell death. In addition, there is a high frequency of keratoconus. ^{22 23} However, as with RDH12 mutations, macular atrophy and marked bone spicule–like pigmentary changes appear with high frequency. In persons with CRB1 mutations, retinas exhibit small white dots and pigment clumps at early ages, as well as moderate to high hyperopia. ²⁴ As with RDH12 mutations, persons with CRB1 mutations exhibit a wide range of visual acuities (from 20/40 to light perception), and decreases to nonrecordable ERG responses. CRX mutations result in a severe, although variable, phenotype. Marked pigmentary retinopathy with bone spicule appearance is observed in less than half of cases; however, marked macular atrophy is present in most cases after age 6. ^{25 26 27 28} In three persons reported to have RPGRIP1 mutations, bone spicule pigmentation and maculopathy were absent, and ERGs were nondetectable in a 15-year-old affected individual. ²⁹  

The severe and early-onset rod–cone degeneration associated with mutations in RDH12 likely reflects a unique requirement for the encoded enzyme that cannot be met by other RDHs expressed in the photoreceptors, including retSDR1, prRDH, and RDH14. ^{7 30 31} The autosomal recessive mode of inheritance, as well as data from in vitro assays of recombinant enzyme activity suggests that RDH12 mutations result in loss-of-function; however, the associated pathophysiological mechanisms have not yet been elucidated. A better understanding of the role of RDH12 photoreceptor physiology and the existence of animal models of the disease are important tasks for the immediate future. 

²  Contributed equally to the work and therefore should be considered equivalent authors.

 Supported by Grants ZR 1/16-1, ZR 1/17-1 KFO 134 (Erbliche Netzhauterkrankungen) of the Deutsche Forschungsgemeinschaft, Grant P17174 from the Austrian Science Fund, and Grant EVI-GENORET LSHG-CT-2005-512036 from the Commission of the European Union.

 Submitted for publication June 9, 2006; revised September 20, 2006; accepted February 12, 2007.

 Disclosure: A. Schuster, None; A.R. Janecke, None; R. Wilke, None; E. Schmid, None; D.A. Thompson, None; G. Utermann, None; B. Wissinger, None; E. Zrenner, None; A. Gal, None

 The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked “advertisement” in accordance with 18 U.S.C. §1734 solely to indicate this fact.

 

Table 1.

 

RDH12 Mutations and Associated Phenotypic Characteristics

Family, Origin, and Genotype	Patient Number	First Symptoms (Age) and Course	Most Recent Phenotype (RE // LE)
						Age	Visual Acuity	Refractive Error	Visual Field	ERG	Anterior Segment and Fundus
I (Austria) p. Y226C homozygous	1	NB, field constriction (early childhood), VA 30/100 (8 y), progressive loss of VA	31	1/50 // 1/50	Emmetropic	Residual temporal field at 50–60°, no central field (III/4e)	Sco: noise level Pho: noise level	SC (bilateral), optic nerve atrophy, central areolar RPE and choroidal atrophy; circular bone-spicule HP in the midperiphery
	2	NB, loss of VA (3 y), color vision deficiency and loss of contrast sensitivity (27 y)	32	LP // HM	0 // +0.75	Concentric constriction to <5° (V/4e)	Sco: noise level Pho: noise level	RE: pseudophakic; LE SC, optic nerve atrophy, central; circular bone spicule HP in the midperiphery
	3	NB, field constriction (early childhood), VA 40/100 (12 y), progressive loss of VA and color vision deficiency	27	LP // HM	Emmetropic	Concentric constriction to <5° (V/4e)	Sco: noise level Pho: noise level	SC (bilateral), optic nerve atrophy, central areolar RPE and choroidal atrophy; circular dense bone spicule HP in the midperiphery
II (Austria) p. Y226C homozygous	4	Field constriction, loss of VA (early childhood); NB (18 y); photophobia (35 y)	49	HM // HM	Emmetropic	Single spots(V/4e)	Sco: noise level Pho: noise level	SC (bilateral), optic nerve atrophy, vessel attenuation, macular RPE atrophy, peripheral RPE atrophy, and HP
	5	NB (20 y), field constriction (25 y), photophobia (30 y)	44	10/200 // 10/200	+1.0 // +0.5	Concentric constriction to 3° (V/4e)	Sco: noise level Pho: noise level	Pseudophakic (bilateral), optic nerve atrophy, vessel attenuation, macular RPE atrophy, peripheral RPE atrophy, and HP
III (Austria) p. Y226C homozygous	6	Progressive field constriction, NB, impairment of VA (early childhood); VA still “sufficient” at age 20 y	69	HM // LP	−3.0 // −2.25	RE concentric constriction to <1° (V/4e)	Sco: noise level Pho: noise level	Posterior SC (bilateral), optic nerve atrophy, vessel attenuation, macular RPE atrophy, peripheral RPE atrophy, and HP
	7	Field constriction, night vision problems; loss of VA (4 y); no nystagmus	7	20/100 // 10/100	+0.5 // +0.75	Concentric constriction to 20–30° // 40° (V/4e)	Residual Sco and Pho 30Hz flicker responses (reduced amp, increased IT), pathological OPs, mfERG: foveal response more affected than peripheral, (reduced amp, increased IT)	Slight SC (bilateral), partial optic nerve atrophy, vessel attenuation, increased macular RPE granularity, peripheral RPE atrophy, and mild HP
IV (Germany) p.A269GfsXI homozygous	8	NB; visual-field constriction; impairment of VA (starting age 4 y): 20/100 // 10/100 (6 y) 10/200 // 10/200 (10 y)	20	LP // 10/200	+5.0 // +6.0	Constriction to 5° small temporal rest (V/4e)	Sco: noise level Pho: noise level	Posterior SC (bilateral), RE: Coats-like vasoproliferation, midperipheral bone spicule HP
V (Turkey) p.Q189X homozygous	9	Loss of VA (early childhood), diagnosis LCA (2 y), NB; VA: 10/200 // 10/200 (23 y)	33	LP // HM	+3.0 // +3.0	NP // NP	Sco: noise level Pho: noise level	Slight posterior SC (bilateral), pale optic nerve, severely narrowed retinal vessels, choroidal atrophy with diffuse RPE defects, and peripheral bone spicule HP.
VI (Turkey) p.A269GfsX1/p.H1 51D	10	NB (early childhood); slowly progressive impairment of VA and field constriction (17 y)	20	10/200 // 10/100	−1.25 // +0.5	Concentric constriction to <5° (III/4e), temporal field of 20°	Sco: noise level Pho: noise level	Slight SC (bilateral), slight narrowing of vessels, macular scars with RPE and choroidal atrophy, and peripheral RPE atrophy with bone spicule HP
VII (Turkey) p.G127X homozygous	11	NB (early childhood); slowly progressive VA loss, progressive visual field constriction: VA: 10/100 // 10/100 (22 y)	33	LP // LP	No data	Temporal field remnants (10–20° diameter)	Sco: noise level Pho: noise level	Slight SC (bilateral), RE // LE: optic nerve atrophy, peripheral RPE atrophy with bone spicule HP
VIII (Saudi-Arabia) p.L274P homozygous	12	NB, visual field constriction (14 y), reduced VA, blurred vision (21 y)	33	HM // HM	No data	V/4e: only minimal temporal field (5° diameter)	Sco: noise level Pho: noise level	Posterior SC (bilateral), optic disc pallor, severely narrowed retinal vessels, macula with choroidal and RPE atrophy, peripheral RPE atrophy with bone spicules
IX (Germany) p.H151 D/p.T155I	13	NB, blurred vision	4	50/100 // 50/100	+3.75 // +4.75	No data	Sco residual responses, Pho amp reduction to 70% of normal range	Anterior segment: normal, normal optic disc, physiological macular reflexes, midperipheral RPE atrophy with bone spicules
X (Germany) p.A269GfsXI homozygous	14	NB, blurred vision, peripheral visual field defects (1 y), VA: 10/100 // 10/100 (9 y)	14	10/100 // 10/100	+5.25 // +6.75	Constriction to 5° (V/4e)	Sco/Pho ERG: residual responses	Anterior segment: normal, normal optic disc, narrowing of retinal vessels; macular pigment mottling; midperipheral RPE atrophy; bone spicules
XI (Germany) p.A269GfsXI homozygous	15	NB (6 y); nystagmus from birth; loss of VA to 40/100 (6 y), peripheral field constriction(12 y)	23	10/100 // 10/100	+2.5 // +1.5	Concentric constriction to 5–8°(III/4e)	np	No data
XII (Germany) p.R65X/ p.A269GfsXI	16	Diagnosis of RP (4 y), documented NB (4 y), progressive loss of VA: 10/30 // 50/100 (5 y), 10/30 // 40/100 (16 y)	30	HM // 10/100	+2.75 // +1.25	Concentric constriction to < 5°, (isopter not indicated)	Sco: noise level Pho: noise level	Pseudophakic (bilateral), RE // LE salt-pepper fundus, optic disc pallor, narrowing of retinal vessels; macular RPE atrophy, peripheral general RPE atrophy, bone spicules

 Family number, country of origin (in brackets) and RDH12 mutation type are indicated in the first (leftmost) column, patient number is listed in the second column, age of onset and course in the third column, age at most recent ophthalmic evaluation in the fourth column, visual acuity of the right eye (RE) // left eye (LE) in the fifth column, the refractive error (spherical equivalent) in the sixth column, visual field data of the right and left eye in the seventh column, ERG data in the eighth column, and anterior segment and fundus characteristics in the ninth column. NB, night blindness; VA, visual acuity LP, light perception; HM, hand movements; NP, not possible; Sco, scotopic; Pho, photopic; amp, amplitude; IT, implicit time; SC, subcapsular cataract; HP, hyperpigmentation.

Figure 1.

 

Standard ERG waveforms (A), multifocal ERG responses (B), kinetic Goldmann visual fields (C), and color vision testing (D) of the right (RE) and left (LE) eyes of patient 7 (at 7 [B–D] and 8 [A] years of age) compared with an unaffected control subject (norm). (A) The traces of standard ERG waveforms show, from top to bottom, 30-Hz photopic response (trace 1), cone response according to ISCEV standard (trace 2), L-cone response (trace 3), rod-, mixed rod–cone responses, and oscillatory potentials according to ISCEV standard (traces 4, 5, and 6, respectively). Trace 1: cone responses to 30 Hz-flicker stimulation, with amplitudes of 27.96 and 22.37 μV for the right and left eyes, respectively. Trace 2: the cone response with amplitudes of 26.21 and 14.72 μV for the right and left eyes, respectively; trace 3: the L-cone response to a single red flash with an amplitude of 21.86 and 11.61 μV for the right and left eyes, respectively. A rod b-wave could be recorded with an amplitude of 41.41 μV and latency of 99 ms for the right eye, and 15.97 μV/91 ms for the left eye. The scotopic mixed rod/cone responses were detectable with an amplitude of 141.81 μV and latency of 72.5 ms for the right eye and 105.99 μV/48.0 ms for the left eye. Trace 6: oscillatory potentials show no detectable response in either eye. (B) Multifocal ERG responses. Top: Trace array of 61 single traces of the right (left lane) and the left (right lane) eyes. Bottom: average responses from areas of equal eccentricity. The method of scaling and averaging used has been described in Sutter and Tran. ¹⁴ (C) The visual field test showed relatively well-preserved outer limits for target V/4e and III/4e on the left eye, with increased constriction on the right eye, possibly influenced by compliance problems. The blind spot was not measurable. (D) Saturated panel D15 test shows that color vision was relatively well preserved in both eyes, with only a few changes detected.

Figure 2.

 

Fundus photographs of persons with RDH12 mutations. For all panels but (C) the left eye is shown. Persons in (A), (C), (D), and (E) are homozygous for the p.Y226C mutation. (A) Patient 7 at age 7 showed partial optic atrophy, moderate vessel attenuation and macular RPE granularity. (B) Patient 8 (homozygous p.A269GfsX1) at age 20 showed macular atrophy and reactive pericentral hyperpigmentation. (C) Patient 3 at 27 years showed marked choroidal and RPE atrophy of the posterior pole, vessel attenuation, and optic atrophy. (D) Patient 1 at age 31 years showed marked choroidal and RPE atrophy of the posterior pole. (E) Patient 6 at age 69 showed macular atrophy and reactive pericentral hyperpigmentation, optic atrophy, and attenuated vessels. Decreased optic quality is due to cataract. (F) Patient 9 (homozygous for p.Q189X) at age 33 showed marked optic and macular atrophy with reactive pericentral hyperpigmentation.