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Ophthalmic Molecular Genetics |

Temporal Macular Thinning Associated With X-Linked Alport Syndrome

Faisal Ahmed, MD; Kandon K. Kamae, MD; Denise J. Jones, BS; Margaret M. DeAngelis, PhD; Gregory S. Hageman, PhD; Martin C. Gregory, MD, PhD; Paul S. Bernstein, MD, PhD
JAMA Ophthalmol. 2013;131(6):777-782. doi:10.1001/jamaophthalmol.2013.1452.
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Importance Optical coherence tomography (OCT) findings of temporal macular thinning are important in the diagnosis and prognosis of X-linked Alport syndrome (XLAS).

Objectives To report OCT findings and severity of temporal macular thinning in a cohort with XLAS and to correlate these and other ocular findings with mutation genotype.

Design Patients with XLAS underwent genotyping for COL4A5 mutations and complete eye examinations with retinal imaging using spectral domain OCT and fundus photography. Temporal macular thinning was calculated from OCT measurements by comparing the ratio of the retinal thickness of the temporal to the nasal subfields with a published normative database.

Setting University departments of ophthalmology and nephrology.

Participants Thirty-two patients from 24 families.

Main Outcome and Measures Temporal thinning index calculated from spectral domain OCT scans.

Results All study patients had a mutation associated with the X-linked COL4A5 gene. Eleven different mutations were identified. Eleven of 32 patients (34%) expressed the L1649R mutation. Of a total of 63 eyes with available OCT scans, 44 (70%) had severe pathological temporal macular thinning. The L1649R mutation was associated with the least amount of severe temporal macular thinning and later onset of renal failure.

Conclusions and Relevance Temporal macular thinning is a prominent sign associated with XLAS, suggesting that OCT measurements are essential in the diagnosis and prognosis of the disease. The L1649R mutation in the COL4A5 gene causes a relatively mild form of XLAS characterized by late-onset renal failure and less frequent, severe temporal macular thinning relative to other COL4A5 mutations. The pathological basis for the retinal abnormalities of XLAS remains to be established.

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Figure 1. Spectral domain optical coherence tomography (OCT) findings and evaluation method. A, Pathological temporal macular thinning of a right eye with X-linked Alport syndrome (XLAS) in an OCT image. B, Normal physiological thinning in a right eye in an OCT image. C, Corresponding grid with subfields at 1-, 3-, and 6-mm diameter-circles labeled T1 (inner temporal), T2 (outer temporal), N1 (inner nasal), and N2 (outer nasal) to represent those areas of the retina. The formula used to determine the temporal thinning index is given in the Temporal Macular Thinning subsection of the Methods section.

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Figure 2. Phenotypic comparison by sex. Ocular findings are reported as the percentage of total eyes for each sex. Renal transplants are reported as the percentage of patients for each sex. XLAS indicates X-linked Alport syndrome.

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Figure 3. Phenotypic comparison between the L1649R and the other 10 mutations. Ocular findings are reported as the percentage of total eyes. Renal transplants are reported as the percentage of patients. XLAS indicates X-linked Alport syndrome.

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