Camiel J. F. Boon, B. Jeroen Klevering, Carel B. Hoyng, Marijke N

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Basal Laminar Drusen Caused by Compound Heterozygous Variants in the CFH Gene  Camiel J.F. Boon, B. Jeroen Klevering, Carel B. Hoyng, Marijke N. Zonneveld-Vrieling, Sander B. Nabuurs, Ellen Blokland, Frans P.M. Cremers, Anneke I. den Hollander  The American Journal of Human Genetics  Volume 82, Issue 2, Pages 516-523 (February 2008) DOI: 10.1016/j.ajhg.2007.11.007 Copyright © 2008 The American Society of Human Genetics Terms and Conditions

Figure 1 Fluorescein Angiogram of the Basal-Laminar Drusen Phenotype Typical fluorescein angiogram of a patient with advanced drusen maculopathy resembling basal laminar drusen (patient 9). Note the typical “stars-in-the-sky” appearance, with central confluence of drusen and the small pseudovitelliform pigment epithelial detachment. The American Journal of Human Genetics 2008 82, 516-523DOI: (10.1016/j.ajhg.2007.11.007) Copyright © 2008 The American Society of Human Genetics Terms and Conditions

Figure 2 Molecular Genetic Analysis of the CFH Gene in Families Affected with Drusen Maculopathy (A and B) Seven affected individuals in two families are compound heterozygous for the nonsense mutation Gln408X and the AMD risk allele Tyr402His. Brackets flanking the CFH variants of A-I.3 indicate that they were deduced through CA-marker analysis. (C) Three affected individuals in a third family are compound heterozygous for the missense variant Arg1078Ser and Tyr402His. (D) Patient D is homozygous for the Tyr402His variant, and in addition, he carries a heterozygous variant in the splice-donor site of exon 3 (c.350+6T→G). (E) A patient in a fifth family carries a heterozygous amino acid variant (Arg567Gly) and is heterozygous for the Tyr402His variant. Segregation analysis could not be performed. Grey pedigree symbols denote patients with basal laminar drusen. The black symbols denote two females affected with AMD. Numbers in the pedigree symbols reflect current age. (F) Sequences of heterozygous variants detected in the CFH gene. The American Journal of Human Genetics 2008 82, 516-523DOI: (10.1016/j.ajhg.2007.11.007) Copyright © 2008 The American Society of Human Genetics Terms and Conditions

Figure 3 Retinal Phenotypes of Drusen Patients Carrying the Combination of a Gln408X Mutation and the Tyr402His AMD Risk Variant (A–D) Retinal phenotype of patient A-III.5. (A) Fundus photograph of the right eye, showing extensive chorioretinal atrophy of the posterior pole. At the first examination, 17 years earlier, these areas corresponded with large confluent drusen with incipient atrophy. (B) The short-wavelength fundus autofluorescence (FAF) image shows an absence of FAF corresponding with the patches of chorioretinal atrophy, not only in the macular area but also in the midperipheral retina. Moreover, diffuse changes in FAF intensity can be observed. (C) Fundus photograph of the left eye, showing large confluent drusen and mild chorioretinal atrophy. (D) An infrared reflectance photograph clearly visualizes small, round, midperipheral drusen scattered between the patches of chorioretinal atrophy. The drusen seen with infrared reflectance corresponded with the discrete, round, yellow-white drusen with a slightly pigmented border seen on ophthalmoscopy. (E–H) Retinal phenotype of patient B-II.1. (E) Fundus photograph showing confluent macular drusen. (F) The macular drusen can be more easily detected on the fluorescein angiogram. (G) Optical coherence tomography (OCT, oblique section) showing small dome-shaped elevations of the “outer red line,” which correspond with the visible drusen on ophthalmoscopy (arrow). (H) Similar to patient A-III.5, small midperipheral drusen were seen in this patient, and OCT revealed aspects similar to the macular drusen. (I and J) Fluorescein angiography showed tiny hyperfluorescent drusen in the parafoveal area and in the (mid-) peripheral retina of Patient B-III.2 (the 22-year-old asymptomatic son of patient B-II.1), but the drusen were difficult to discern on ophthalmoscopy. His 25-year-old brother (B-III.1) had similar midperipheral lesions, but to a lesser extent. The American Journal of Human Genetics 2008 82, 516-523DOI: (10.1016/j.ajhg.2007.11.007) Copyright © 2008 The American Society of Human Genetics Terms and Conditions

Figure 4 Molecular Modeling of Missense Variants Detected in CFH (A and B) Model of the SCR18 domain, depicting the effect of the Arg1078Ser variant. (A) wild-type sequence (Arg1078). (B) Arg1078Ser variant. (C and D) Model of the SCR9 and SCR10 domains, depicting the effect of the Arg567Gly variant. (C) wild-type sequence (Arg567). (D) Arg567Gly variant. The SCR9 domain is shown in yellow, the SCR10 domain in orange, and the linker region between the two domains is shown in blue. Hydrogen-bonding partners for the residues in the linker region are indicated with dotted lines. All figures were made with Yasara. The American Journal of Human Genetics 2008 82, 516-523DOI: (10.1016/j.ajhg.2007.11.007) Copyright © 2008 The American Society of Human Genetics Terms and Conditions