1. דרור שרון, Ph.D. מחלקת עיניים הדסה, עין-כרם Dror Sharon, PhD Dept. Of Ophthalmology Hadassah-Hebrew University Medical Center, Jerusalem The Genetics of Inherited Retinal Diseases in the Palestinian Population- Preliminary data

2. Inherited Human Diseases Disease Autosomal Recessive Cystic Fibrosis Autosomal Recessive Tay-Sachs disease Gene CFTR HEXAMonogenic Disease Schizophrenia Obesity Gene >10 loci Polygenic / Multifactorial

3. Inherited Human Diseases- Allelic heterogeneity Disease Doyne honeycomb retinal dystrophy Gene EFEMP1 (fibulin3)- Arg345Trp NDP-Arg90Pro NDP-Ser75His NDP-Val60Glu NDP-Tyr44Cys NDP-Cys96Tyr NDP-Leu124Phe NDP-Cys69Ser NDP-Cys128Ter X-linked Norrie disease

4. Disease Autosomal Dominant RP (ADRP) Autosomal Recessive RP (ARRP) X-linked RP (XLRP) Starting point- 1989 Gene

5. Rhodopsin Disease Autosomal Dominant RP (ADRP) Autosomal Recessive RP (ARRP) X-linked RP (XLRP)

6. Disease Dominant RP Recessive RP X-linked RP LCA Congenital Night Blindness Oguchi Macular degeneration Stargardt CRD ESCS Goldmann-Favre Clumped pigment AMD Gene Rhodopsin

7. Gene Phototransduction Rhodopsin Arrestin rod a-channel rod b-channel a-PDE b-PDE GUCA1B Vitamin A cycle ABCA4 LRAT RGR RLBP1 RPE65 Other function CERKL MERTK CA4 FSCN2 IMPDH1 RDS ROM1 RP9 Transcription factors CRX NRL Splicing factors PRPF3 PRPF8 PRPF31 Unknown function CRB1 RP1 TULP1 USH2A RP2 RPGR RP inheritance pattern Autosomal Dominant RP (ADRP- 13 genes) Autosomal Recessive RP (ARRP- 11 genes; 5 loci) X-linked RP (XLRP- 2 genes; 3 loci)

8. Disease Dominant RP Digenic RP Recessive RP X-linked RP LCA SNB Oguchi Color blindness Macular degeneration Stargardt CRD ESCS Goldmann-Favre Clumped pigment Gene Phototransduction Rhodopsin Arrestin Rhodopsin kinase alpha-Transducin a-PDE b-PDE rod a-channel rod b-channel cone a-channel cone b-channel GUCA1A GUCY2D Vitamin A cycle RPE65 ABCR LRAT RGR RBP4 RDH5 CRALBP Transcription factors NRL CRX NR2E3 Other function RDS ROM1 PRPC8 PRPF31 Complement Factor H Unknown RPGR RP2 CRB1 Ush2A EFEMP1 MERTK PROML1 TULP1 ELOVL4 RP1 VMD2 RPGRIP1 AIPL1 FSCN2 NYX CACNA1F

9. Phototransduction- G protein cascade

10. Frequency of carriers for ARRP mutations

11. The evolving story of a heterogeneous disease

12. The Cohort of Patients

13. Genetic Research at Hadassah 1.Genetic research began in 2003. 2.Patient recruitment: mostly after ERG testing (headed by Prof. Benin), Ophthalmologists, Genetic counselors, website. 3.More than 1000 families were recruited thus far, mostly with inherited retinal degenerations. 4.We recruit about 100 new families annually.

14. Patients from the Palestinian Territories 1.Patient recruitment: ERG testing at Hadassah / recruitment at St. John (Prof. Merin). 2.A set of 261 families and 600 patients (about 25% of our cohort). 3.Two major limitations: A. Usually only the index case is recruited. B. A low rate of success in re-contacting patients.

15. Distribution of different retinal phenotypes

16. Distribution of Inheritance Patterns for RP isolate XL AR AD

17. Rate of Consanguinity in the Cohort of Patients isolate XL AR AD

18. Identical by decent locus Homozygous Region

19. Homozygosity mapping using 10K SNP array in families with CRD

20. Homozygosity CNGA3 delATC@I314 22bp Duplication

21. Founder Mutations in the Palestinian population

22. Founder mutations No. of patients PhenotypeMutationGene 25AchromatopsiaVal529MetCNGA3 30AchromatopsiadelATC@I314CNGA3 11Achromatopsiac.126_147dup22CNGA3 5AchromatopsiaGly329CysCNGA3 27CSNBLys294XTRPM1 20STGD type IIIIVS28-15del23bpABCA4 Additional genes: BEST1, RDH5, RDH12, ADAM9, NR2E3, CRB1, TULP1, FAM161A, EYS, RPGR

23. Percentage of cases in which the genetic cause was identified

24. Stargardt disease, Cone-rod degeneration, and the ABCA4 gene

25. MOL0033 ? 5 6 6 3:3 2:2 MOL0006 9 7 4:4 ? 2:2 4 Stargardt type III and the ABCA4 gene

26. Fundus photos Affected son age: 22 The mother age: 42 Affected son age: 13

27. Retinal function

28. 1. A microarray analysis of all 437 known ABCA4 sequence changes did not reveal any pathogenic mutations. 2. SSCP and sequencing analysis of all 50 ABCA4 exons revealed two novel pathogenic mutations. 21222324252627282930 aagaactgctttggcaca K N C F G T Cystein 1150 del aagaactttggcaca K N F G T Mutation analysis of the ABCA4 gene

29. 22 11 AA GG 11 22 MOL0006 D1S435 D1S188 rs472908 rs560426 D1S2719 D1S497 2311AGGG11232311AGGG11231G1 21 2211AGGA11212211AGGA11211 22 11 AA GG 11 32 3211GAGG11323211GAGG11321G1 22 11 AA GG 11 22 11 AA GG 11 22 ABCA4 32--GAGG--3232--GAGG--32-G- 32--GAGG--3232--GAGG--32-G- 32--GAGG--3232--GAGG--32-G- 32 -- GG GA -- 312- 22--AGGA--2122--AGGA--21- 22 11 AA GG 11 32 Cystein 1150 del IVS28-15del23bp ABCA4 mutation analysis Compound hetrozygotes- Mild phenotype Homozygotes- Severe phenotype

30. 1. We predict that only a small fraction of families with inherited retinal disease was studied so far. 2. Setting up an ophthalmic genetic laboratory in a Palestinian University will enhance gene identification. 3. How will the Palestinian patients benefit from these studies? CONCLUSIONS

31. Lab Team Lina Zelinger Dikla Bandah-Rozenfeld Liliana Mizrahi-Meissonnier

32. Collaborators European Collaborators: Dr. Susanne Kohl Prof. Bernd Wissinger Prof. Frans Cremers Dr. Anneke den Hollander Dr. Rob Collin Funding: The Foundation Fighting Blindness (FFB) Israeli Ministry of Health- Amutat Lirot Israeli Science Foundation (ISF) Binational Science Foundation (BSF) American Collaborators: Prof. Samuel G. Jacobson Dr. Artur V. Cideciyan Sharon B. Schwartz Israeli Collaborators: Prof. Eyal Banin Prof. Saul Merin Dr. Shahar Frenkel Prof. Itay Chowers Prof. Jacob Pe`er Dr. Dalia Eli Dr. Anat Blumenfeld Dr. Tamar Ben-Yosef Dr. Alexey Obolensky Prof. Ruth Ashery-Padan