A third possibility to consider was that heterozygous
MPDZ variants could act as modifiers of disease severity caused by mutations in other retinal dystrophy genes, or act in concert with mutations in other genes to cause digenic or trigenic disease.
13,14 The
MPDZ variant, p.P1598L, that did not segregate with LCA (
Supplementary Fig. S5) could act as a modifier, leading to a more severe phenotype. However, detailed clinical data were not available for this family, which was recruited in rural Pakistan; hence, no useful comparison could be made between family members with and without the
MPDZ allele. Given the known interaction between MPDZ and CRB1, this would appear the most likely locus/modifier pairing. However, because
RPE65 (MIM +180,069) is similar to
CRB1 in that mutations can cause either RP or LCA, this gene was also considered a potential partner.
9,10,15–17 The possibility of digenic or trigenic inheritance with
CRB1 or
RPE65 mutations was investigated by sequencing the entire coding region and splice recognition signals of these genes in the 10 patients with
MPDZ sequence changes. Primer sequences used are depicted in (
Supplementary Table S3). We identified homozygous
CRB1 gene mutations in two LCA patients and
RPE65 mutations in another two.
GUCY2D (MIM *600179) mutations had been found in the fifth LCA case (SGJ, unpublished data, 2010). The results are summarized in
Table 1. Notably, the RP patients with
MPDZ variants did not have
CRB1 or
RPE65 mutations. This could imply that patients with certain
CRB1,
RPE65, or
GUCY2D mutations have more severe disease (LCA) when a heterozygous
MPDZ variant is also present, whereas the
MPDZ variants seen in RP patients could be dominant alleles or could modify the severity of mutations in retinal genes other than
CRB1 and
RPE65 leading to RP.