Virginia Mason Institute

• To evaluate antiallergic agents, we conducted five allergen challenge studies of increasing refinement. The final study design that evolved included two baseline visits, when skin test-positive subjects were administered a bilateral ocular allergen challenge. At the first visit, the threshold dose of reactivity was determined by increasing allergen doses at 10-minute intervals. At the second baseline visit, 3 days later, the responsive subjects were challenged with the final, highest dose used on visit 1 to assure that the allergic reaction was reproducible and not a cumulative effect of multiple allergen doses. The responsive subjects then returned 3 days later for the drug efficacy evaluation. After a slit-lamp examination, subjects were pretreated with the test drug in one eye and the placebo in the fellow eye in a randomized, double-masked fashion. After 10 minutes, subjects were challenged bilaterally with the allergen dose identified on the previous visits. Postchallenge evaluations of hyperemia, itching, chemosis, eyelid swelling, and tearing were performed at 3, 10, and 20 minutes. Subjects were rechallenged 4 hours after drug administration to assess duration of action. Slit-lamp examinations were again performed at the same intervals as after the initial challenge. A total of 396 subjects were given a baseline allergen challenge; 83.6% responded with a moderate (2+) ocular allergic reaction. Of the 266 given a second baseline challenge, 87.2% responded positively again, suggesting that ocular challenge was highly correlated with skin reactivity and reproducible with a second challenge. No statistically significant difference in redness and itching was found when both eyes were challenged with the same dose of allergen. There was a significant decrease in the allergic reaction of a placebo-pretreated eye compared with its baseline response, and the response to rechallenge was less than the initial one. Of the 950 challenges administered, only two mild systemic reactions occurred, demonstrating the safety of this incremental challenge method. We conclude that this method of allergen challenge is safe, reproducible, and symmetric, but a refractory period may exist when the eye is challenged a third and fourth time in an 8-day period. We now separate the challenge visits by 7 days.

Canine degenerative myelopathy (DM) is a fatal neurodegenerative disease prevalent in several dog breeds. Typically, the initial progressive upper motor neuron spastic and general proprioceptive ataxia in the pelvic limbs occurs at 8 years of age or older. If euthanasia is delayed, the clinical signs will ascend, causing flaccid tetraparesis and other lower motor neuron signs. DNA samples from 38 DM-affected Pembroke Welsh corgi cases and 17 related clinically normal controls were used for genome-wide association mapping, which produced the strongest associations with markers on CFA31 in a region containing the canine SOD1 gene. SOD1 was considered a regional candidate gene because mutations in human SOD1 can cause amyotrophic lateral sclerosis (ALS), an adult-onset fatal paralytic neurodegenerative disease with both upper and lower motor neuron involvement. The resequencing of SOD1 in normal and affected dogs revealed a G to A transition, resulting in an E40K missense mutation. Homozygosity for the A allele was associated with DM in 5 dog breeds: Pembroke Welsh corgi, Boxer, Rhodesian ridgeback, German Shepherd dog, and Chesapeake Bay retriever. Microscopic examination of spinal cords from affected dogs revealed myelin and axon loss affecting the lateral white matter and neuronal cytoplasmic inclusions that bind anti-superoxide dismutase 1 antibodies. These inclusions are similar to those seen in spinal cord sections from ALS patients with SOD1 mutations. Our findings identify canine DM to be the first recognized spontaneously occurring animal model for ALS.

alpha-Crystallin, the major protein of the ocular lens, acts as a molecular chaperone by suppressing the nonspecific aggregation of damaged proteins. To investigate the mechanism of the interaction between alpha-crystallin and substrate proteins, we prepared a tryptophan-free mutant of human alpha A-crystallin and assessed the conformation of thermally destabilized proteins captured by this chaperone using fluorescence spectroscopy. The fluorescence emission characteristics of bound substrates (rhodanese and gamma-crystallin) and the results of fluorescence quenching experiments indicate that the proteins captured by alpha-crystallin are characterized by a very low degree of unfolding. In particular, the structure of rhodanese bound to alpha A-crystallin appears to be considerably more native-like compared to that of the enzyme bound to the chaperonin GroEL. We postulate that alpha-crystallin (and likely other small heat shock proteins) recognize preferentially the aggregation-prone conformers that occur very early on the denaturation pathway. With its ability to capture and stabilize these early non-native structures, alpha-crystallin appears to be uniquely well suited to chaperone the transparency properties of the ocular lens.

BACKGROUND: Previous reports associated 2 mutant SOD1 alleles (SOD1:c.118A and SOD1:c.52T) with degenerative myelopathy in 6 canine breeds. The distribution of these alleles in other breeds has not been reported. OBJECTIVE: To describe the distribution of SOD1:c.118A and SOD1:c.52T in 222 breeds. ANIMALS: DNA from 33,747 dogs was genotyped at SOD1:c.118, SOD1:c.52, or both. Spinal cord sections from 249 of these dogs were examined. METHODS: Retrospective analysis of 35,359 previously determined genotypes at SOD1:c.118G>A or SOD1:c.52A>T and prospective survey to update the clinical status of a subset of dogs from which samples were obtained with a relatively low ascertainment bias. RESULTS: The SOD1:c.118A allele was found in cross-bred dogs and in 124 different canine breeds whereas the SOD1:c.52T allele was only found in Bernese Mountain Dogs. Most of the dogs with histopathologically confirmed degenerative myelopathy were SOD1:c.118A homozygotes, but 8 dogs with histopathologically confirmed degenerative myelopathy were SOD1:c.118A/G heterozygotes and had no other sequence variants in their SOD1 amino acid coding regions. The updated clinical conditions of dogs from which samples were obtained with a relatively low ascertainment bias suggest that SOD1:c.118A homozygotes are at a much higher risk of developing degenerative myelopathy than are SOD1:c.118A/G heterozygotes. CONCLUSIONS AND CLINICAL IMPORTANCE: We conclude that the SOD1:c.118A allele is widespread and common among privately owned dogs whereas the SOD1:c.52T allele is rare and appears to be limited to Bernese Mountain Dogs. We also conclude that breeding to avoid the production of SOD1:c.118A homozygotes is a rational strategy.

PURPOSE: Keratoconus (KC) is characterized by progressive vision loss due to corneal thinning and structural abnormalities. It is hypothesized that KC is caused by deregulated collagen levels and collagen fibril-maturating enzyme lysyl oxidase (LOX). Further, it is currently not understood whether the gene expression deregulated by the corneal epithelium influences KC pathogenesis. We studied (i) the expressions of the LOX, collagen I (COL IA1), collagen IV (COL IVA1), MMP9, and IL6 genes in KC corneal epithelia, (ii) validated their expression levels in patient tissues, and (iii) correlated expression levels with KC disease severity. The primary goal of this study was to evaluate the importance of these genes in the progression of KC. METHODS: We analyzed the gene expression levels of the key proteins LOX, collagens (COL IA1 and COL IVA1), MMP9, and IL6 in debrided corneal epithelia from a large cohort of KC patients (90 eyes) and compared them to control patients (52 eyes) without KC. We measured the total LOX activity in the tears of KC patients compared to controls. We also correlated the protein expression levels of LOX and collagens by immunohistochemistry (IHC) in primary tissues from KC patients (27 eyes) undergoing keratoplasty compared to healthy donor corneas (15 eyes). RESULTS: We observed a significant reduction in LOX transcript levels in KC corneal epithelia, and LOX activity in KC tears correlated with disease severity. Collagen transcripts were also reduced in KC while MMP9 transcript levels were upregulated and correlated with disease severity. IL6 was moderately increased in KC patients. IHC demonstrated a reduction in the protein expression levels of LOX in the epithelium and collagen IV in the basement membrane of KC patients compared to healthy donor corneas. CONCLUSIONS: The data demonstrates that the structural deformity of the KC cornea may be dependent on reduced expressions of collagens and LOX, as well as on MMP9 elevated by the corneal epithelium.

PURPOSE: This study tested a hypothesis that tissue-selective targeted decorin gene therapy delivered to the stroma with adeno-associated virus serotype 5 (AAV5) inhibits corneal fibrosis in vivo without significant side effects. METHODS: An in vivo rabbit model of corneal fibrosis was used. Targeted decorin gene therapy was delivered to the rabbit cornea by a single topical application of AAV5 (100 μL; 6.5 × 10(12) μg/mL) onto the bare stroma for 2 minutes. The levels of corneal fibrosis were determined with stereomicroscopy, slit lamp biomicroscopy, α-smooth muscle actin (αSMA), fibronectin, and F-actin immunocytochemistry, and/or immunoblotting. CD11b, F4/80 immunocytochemistry, and TUNEL assay were used to examine immunogenicity and cytotoxicity of AAV5 to the cornea. Transmission electron microscopy (TEM) was used to investigate ultrastructural features. Slot-blot-quantified the copy number of AAV5-delivered decorin genes. RESULTS: Selective decorin delivery into the stroma showed a significant (P < 0.01) decrease in corneal haze (1.3 ± 0.3) compared with the no-decorin-delivered control rabbit corneas (3 ± 0.4) quantified using slit lamp biomicroscopy. Immunostaining and immunoblot analyses detected significantly reduced levels of αSMA, F-actin, and fibronectin proteins (59%-73%; P < 0.001 or <0.01) in decorin-delivered rabbit corneas compared with the no-decorin-delivered controls. The visual clinical eye examination, slit lamp clinical studies, TUNEL, CD11b, and F4/80 assays revealed that AAV5-mediated decorin gene therapy is nonimmunogenic and nontoxic for the cornea. TEM studies suggested that decorin gene delivery does not jeopardize collagen fibrillogenesis as no significant differences in collagen fibril diameter and arrangement were observed in decorin-delivered and no-decorin-delivered control corneas. CONCLUSIONS: Tissue-targeted AAV5-mediated decorin gene therapy is effective and safe for treating corneal fibrosis in vivo.

PURPOSE: To characterize rod- and cone-driven oscillatory potentials (OPs) in mice. METHODS: Dark- and light-adapted electroretinograms (ERGs) were obtained in three mouse models: wild-type C57BL/6J mouse, cone photoreceptor function loss 1 (cpfl1) mouse, and rhodopsin knockout (rho-/-) mouse. A Butterworth filter was used to extract OPs from ERG signals. Latencies were calculated from the extracted OPs. Major frequency components were determined from OP power spectra computed using fast Fourier transform (FFT). The total power of the OP signal (an alternative measurement of amplitude) was calculated by numerically integrating the area enclosed by its frequency spectra, which is analogous to the total energy of mechanical vibration. RESULTS: In C57BL/6J mice, dark- and light-adapted OPs had distinctly different peak frequencies (100 to 120 Hz and 70 to 85 Hz, respectively). In cpfl1 mice which possess pure rod ERGs, dark-adapted OPs had a peak frequency similar to those of the wild-type mice, whereas light-adapted ERGs and OPs were not detectable. In rho-/- mice with pure cone functions, both dark-adapted and light-adapted OPs had peak frequencies of 70 to 90 Hz, which were similar to those obtained from light-adapted OPs in wild-type mice. The total power of cone-driven OPs was less than 5% that of rod-driven OPs. In time-domain, cone-driven OPs occurred approximately 13 ms after rod-driven OPs. CONCLUSIONS: Cone- and rod-driven OPs exhibit significantly different characteristics in peak frequency, latency, and total power. By using these characteristics, it is possible to differentiate cone- and rod-driven OPs in mouse models. Understanding these OP features is essential for analyzing OPs.

PURPOSE: Batten disease, also known as juvenile ceroid-lipofuscinosis and CLN3, is an autosomal recessively inherited disorder that results in blindness due to retinal degeneration. The CLN3 gene has been identified, but the function of the protein that this gene encodes is unknown. Experiments were conducted to determine where the CLN3 protein is localized in the mouse retina. Localization should provide a clue in evaluating potential functions of this protein. METHODS: Using oligonucleotide primers based on the reported human CLN3 cDNA sequence, the mouse cDNA nucleotide sequence was determined from products of the reverse transcriptase-polymerase chain reaction and 3' rapid amplification of cDNA ends. A synthetic 20-amino-acid peptide corresponding to an internal hydrophilic region of the predicted amino acid sequence of the mouse CLN3 protein was used to immunize rabbits. The resulting antiserum was used in immunoblot analysis of mouse retina homogenates and in electron microscopic immunocytochemical labeling of mouse retina sections. RESULTS: The peptide antibody labeled a single protein band of approximately 50 kDa on immunoblots of mouse retina homogenates. No labeling was detected with homogenates from human retinas. The antibody specifically labeled mitochondria of Müller cells and inner retinal neurons. Little labeling was observed in mitochondria of the photoreceptor cells. Mitochondria of other cell types, including the retinal pigment epithelium and choroidal cells, were not labeled. CONCLUSIONS: The retinal CLN3 protein appears to be localized almost exclusively in the mitochondria, but was detected only in certain cell types. Batten disease is characterized by massive lysosomal accumulations of a small inner mitochondrial membrane protein (subunit c of ATP synthase). The mitochondrial localization of the CLN3 protein suggests that it may play a role in the normal processing of subunit c.

We followed up 45 eyes with early-stage idiopathic macular hole (mean period, 32 months; range, 7 to 87 months) to investigate their prognoses, especially in relation to the vitreous condition. At initial examination, 18 eyes (40%) showed vitreous separation from the fovea, and 10 (22%) developed vitreous separation during follow-up. None of these 28 eyes progressed to a fully developed macular hole during follow-up. Moreover, the macular disease was apparently improved in 23 (82%) of these eyes. However, of the remaining 27 eyes without vitreous separation from the fovea, 10 eyes (37%) progressed to a fully developed macular hole. We speculate that early-stage macular hole could be reversed by spontaneous vitreous separation from the fovea, and this chance may be greater than the risk of true macular hole formation.

Neuronal ceroid lipofuscinoses (NCLs) are inherited neurodegenerative diseases characterized by accumulations of autofluorescent lipopigments within cells of the nervous system. Nine related American Bulldogs demonstrated dysmetria in all limbs and paraparesis. Nonambulatory tetraparesis was observed only in the later stages of the disease. The clinical signs developed between 1 and 3 years of age and were slowly progressive over several years, which is inconsistent with most reports in other breeds. Results from blood tests for 8 different lysosomal storage diseases on 4 affected and 6 related but unaffected dogs were negative. Four affected dogs were euthanized and histopathologic examinations showed diffuse accumulations of periodic acid-Schiff-positive inclusions in neurons and axonal spheroids along the entire neuraxis and retinae. The most severe lesions were in the brainstem proprioceptive nuclei and spinal cord, consistent with clinical signs. The storage material was autofluorescent and immunohistochemically positive for products of lipid peroxidation. Ultrastructural analysis was consistent with NCL. Pedigree analysis supports an autosomal-recessive mode of inheritance. NCL has not been previously reported in the American Bulldog and these findings suggest a variant form of the canine disease.

OBJECTIVE: To investigate the clinical, histologic, and electroretinographic effects of intravitreal injection of triamcinolone acetonide suspension in the rabbit retina. METHODS: Three groups of 6 rabbits each received intravitreal injections. Group 1 received 4 mg of triamcinolone acetonide, group 2 received an equal volume (0.1 mL) of the corticosteroid supernatant, and group 3 received 4 mg of triamcinolone acetonide with the supernatant replaced with balanced salt solution. Uninjected left eyes served as controls. Electroretinograms were obtained at baseline and at 3 to 4 and 6 to 7 days after injection of triamcinolone. Enucleated eyes were examined histologically. RESULTS: Ocular examination revealed no differences among the 3 groups. When subjected to stimulation with moderate to high flash intensities, eyes that had received intravitreal injections of triamcinolone (groups 1 and 3) had a 10% to 25% increase in dark-adapted a- and b-wave electroretinographic amplitudes. No histologic differences were observed between injected and control eyes. CONCLUSIONS: Intravitreal injection of 4 mg of triamcinolone acetonide does not cause a toxic reaction in the rabbit retina after 7 days. Triamcinolone therapy may augment the rod-driven electroretinographic responses, suggesting a mechanism by which visual function may improve. Clinical Relevance Evaluation of the toxic effects of triamcinolone is useful because of increased applications of intravitreal injection.

BACKGROUND: Neuronal ceroid lipofuscinosis (NCL), a fatal neurodegenerative disease, has been diagnosed in young adult Australian Cattle Dogs. OBJECTIVE: Characterize the Australian Cattle Dog form of NCL and determine its molecular genetic cause. ANIMALS: Tissues from 4 Australian Cattle Dogs with NCL-like signs and buccal swabs from both parents of a fifth affected breed member. Archived DNA samples from 712 individual dogs were genotyped. METHODS: Tissues were examined by fluorescence, electron, and immunohistochemical microscopy. A whole-genome sequence was generated for 1 affected dog. A TaqMan allelic discrimination assay was used for genotyping. RESULTS: The accumulation of autofluorescent cytoplasmic storage material with characteristic ultrastructure in tissues from the 4 affected dogs supported a diagnosis of NCL. The whole-genome sequence contained a homozygous nonsense mutation: CLN5:c.619C>T. All 4 DNA samples from clinically affected dogs tested homozygous for the variant allele. Both parents of the fifth affected dog were heterozygotes. Archived DNA samples from 346 Australian Cattle Dogs, 188 Border Collies, and 177 dogs of other breeds were homozygous for the reference allele. One archived Australian Cattle Dog sample was from a heterozygote. CONCLUSIONS AND CLINICAL IMPORTANCE: The homozygous CLN5 nonsense is almost certainly causal because the same mutation previously had been reported to cause a similar form of NCL in Border Collies. Identification of the molecular genetic cause of Australian Cattle Dog NCL will allow the use of DNA tests to confirm the diagnosis of NCL in this breed.

The ability of hyaluronidase to improve akinesis in retrobulbar anesthesia was evaluated in a double-masked study. Forty consecutive patients undergoing cataract surgery were anesthetized with 3 ml of a 1:1 mixture of 4.0% lidocaine and 0.75% bupivacaine solution. In a predetermined randomized fashion, 2 ml of hyaluronidase (300 USP units) were added to half of the syringes, and 2 ml of saline to the remaining half. The level of akinesia was graded in six different positions of gaze. Seventy percent of the hyaluronidase group exhibited complete akinesis, while only 40% of the control group did. The mean scores for four out of six positions of gaze were significantly higher in the hyaluronidase patients than in the control group. Similarly, the hyaluronidase subjects showed a significantly higher sum score for the six sectors than did the control subjects (p = .0001). These results show that hyaluronidase significantly enhances akinesia. It is therefore recommended that it be included in the anesthetic regimen for such surgeries.

BACKGROUND: Bandera's neonatal ataxia (BNAt) is an autosomal recessive cerebellar ataxia that affects members of the Coton de Tulear dog breed. OBJECTIVE: To identify the mutation that causes BNAt. ANIMALS: The study involved DNA from 112 Cotons de Tulear (including 15 puppies with signs of BNAt) and 87 DNA samples from dogs of 12 other breeds. METHODS: The BNAt locus was mapped with a genome-wide association study (GWAS). The coding exons of positional candidate gene GRM1, which encodes metabotropic glutamate receptor 1, were polymerase chain reaction (PCR)-amplified and resequenced. A 3-primer PCR assay was used to genotype individual dogs for a truncated retrotransposon inserted into exon 8 of GRM1. RESULTS: The GWAS indicated that the BNAt locus was in a canine chromosome 1 region that contained candidate gene GRM1. Resequencing this gene from BNAt-affected puppies indicated that exon 8 was interrupted by the insertion of a 5'-truncated retrotransposon. All 15 BNAt-affected puppies were homozygous for the insert, whereas all other Cotons de Tulear were heterozygotes (n = 43) or homozygous (n = 54) for the ancestral allele. None of the 87 dogs from 12 other breeds had the insertion allele. CONCLUSIONS AND CLINICAL IMPORTANCE: BNAt is caused by a retrotransposon inserted into exon 8 of GRM1. A DNA test for the GRM1 retrotransposon insert can be used for genetic counseling and to confirm the diagnosis of BNAt.

A 10-month-old spayed female Cane Corso dog was evaluated after a 2-month history of progressive blindness, ataxia, and lethargy. Neurologic examination abnormalities indicated a multifocal lesion with primarily cerebral and cerebellar signs. Clinical worsening resulted in humane euthanasia. On necropsy, there was marked astrogliosis throughout white matter tracts of the cerebrum, most prominently in the corpus callosum. In the cerebral cortex and midbrain, most neurons contained large amounts of autofluorescent storage material in the perinuclear area of the cells. Cerebellar storage material was present in the Purkinje cells, granular cell layer, and perinuclear regions of neurons in the deep nuclei. Neuronal ceroid lipofuscinosis (NCL) was diagnosed. Whole genome sequencing identified a PPT1c.124 + 1G>A splice donor mutation. This nonreference assembly allele was homozygous in the affected dog, has not previously been reported in dbSNP, and was absent from the whole genome sequences of 45 control dogs and 31 unaffected Cane Corsos. Our findings indicate a novel mutation causing the CLN1 form of NCL in a previously unreported dog breed. A canine model for CLN1 disease could provide an opportunity for therapeutic advancement, benefiting both humans and dogs with this disorder.

PURPOSE: The amounts of autofluorescent lysosomal storage bodies, known as lipofuscin, increase during senescence in the retinal pigment epithelia (RPEs) of mammalian eyes. This increase in lipofuscin content may result from a failure of the RPE to dispose of any lipofuscin constituents once they have formed. Alternatively, the RPE may eliminate lipofuscin but at a rate insufficient to prevent its accumulation. Experiments were conducted to distinguish between these two possibilities. METHODS: Albino rats were given intravitreal injections of the protease inhibitor leupeptin, which induces a rapid accumulation of lipofuscin-like inclusions in the RPE. The amount of these inclusions in the RPE was monitored as a function of time after the leupeptin treatment with quantitative ultrastructural analysis. In addition, the intensity of lipofuscin-specific fluorescence in the RPE was monitored over the same time period with the use of quantitative microfluorometry. These parameters were also followed in untreated control eyes of age-matched animals. RESULTS: A single leupeptin injection resulted in a rapid massive accumulation of electron-dense inclusion bodies in the RPE. These inclusions appeared to be derived primarily from phagocytosed photoreceptor outer segments. Accompanying the accumulation of these inclusions was a significant increase in lipofuscin-specific fluorescence in the RPE. Over a 12-week period after the leupeptin treatment, the amounts of inclusion material and the fluorescence intensities returned to normal levels. CONCLUSIONS: These findings suggest that the age-related increase in RPE lipofuscin content results from an imbalance in the rates of lipofuscin formation and disposal rather than from a complete absence of a disposal mechanism. The results imply that turnover of lipofuscin constituents may be rapid relative to the animals' life span. Thus, it may be possible to slow or reverse the age-related increase in RPE lipofuscin content by either inhibiting the processes involved in lipofuscin formation or enhancing the disposal processes.

The chaperone activity and biophysical properties of the 19 amino acid peptide DFVIFLDVKHFSPEDLTVK, identified as the functional element in alphaA-crystallin and here referred to as mini-alphaA-crystallin, were studied using light scattering and spectroscopic methods after altering its sequence and enantiomerism. The all-D and all-L conformers of the peptide do not show marked differences in their chaperone-like activity against heat-induced aggregation of alcohol dehydrogenase at 48 degrees C and dithiothreitol-induced aggregation of insulin. The retro peptide does not show any secondary structure and is also unable to act like a chaperone. Both all-L and all-D peptides lose their beta-sheet conformations, hydrophobicity and chaperone-like activity at temperatures > 50 degrees C. However, upon cooling, a significant portion of those properties was regained, suggesting temperature-dependent, reversible structural alterations in the peptides under investigation. We propose that both the hydrophobicity and beta-sheet conformation of the functional element of alphaA-crystallin are essential for chaperone-like activity.

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Consistent with a tentative diagnosis of neuronal ceroid lipofuscinosis (NCL), autofluorescent cytoplasmic storage bodies were found in neurons from the brains of 2 related Shiba Inu dogs with a young-adult onset, progressive neurodegenerative disease. Unexpectedly, no potentially causal NCL-related variants were identified in a whole-genome sequence generated with DNA from 1 of the affected dogs. Instead, the whole-genome sequence contained a homozygous 3 base pair (bp) deletion in a coding region of HEXB. The other affected dog also was homozygous for this 3-bp deletion. Mutations in the human HEXB ortholog cause Sandhoff disease, a type of GM2 gangliosidosis. Thin-layer chromatography confirmed that GM2 ganglioside had accumulated in an affected Shiba Inu brain. Enzymatic analysis confirmed that the GM2 gangliosidosis resulted from a deficiency in the HEXB encoded protein and not from a deficiency in products from HEXA or GM2A, which are known alternative causes of GM2 gangliosidosis. We conclude that the homozygous 3-bp deletion in HEXB is the likely cause of the Shiba Inu neurodegenerative disease and that whole-genome sequencing can lead to the early identification of potentially disease-causing DNA variants thereby refocusing subsequent diagnostic analyses toward confirming or refuting candidate variant causality.

The effects of optical defocusing with convex lenses on the amplitudes of pattern reversal visual-evoked response (PVER) were investigated. With the large check size and high-contrast pattern, PVER amplitudes showed a linear decrease in response to initial defocusing up to +5 to +6 dptr. As the degree of defocus increased, the PVER amplitude, though irregular, continued to show reliable, definite responses up to +25 dptr. With the intermediate check size and pattern contrast, PVER amplitudes displayed a linear decrease, but unlike the large-check/high-contrast condition, diminished to noise level after a defocus of greater than +4 to +5 dptr. From these results, we speculate that two phases in this function curve derive from the large-check/high-contrast condition: first, the contrast- or contour-dependent phase, and, second, the luminosity/movement-dependent phase.