Vinit B. Mahajan

Connectin: A homophilic cell adhesion molecule expressed on a subset of muscles and the motoneurons that innervate them in Drosophila

Each abdominal hemisegment in the Drosophila embryo contains a stereotyped array of 30 muscles, each specifically innervated by one or a few motoneurons. We screened 11,000 enhancer trap lines, isolated several expressing beta-galactosidase in small subsets of muscle fibers prior to innervation, and identified two of these as inserts in connectin and Toll, members of the leucine-rich repeat gene family. Connectin contains a signal sequence, ten leucine-rich repeats, and a putative phosphatidylinositol membrane linkage; in S2 cells, connectin can mediate homophilic cell adhesion. Connectin is expressed on the surface of eight muscles, the motoneurons that innervate them, and several glial cells along the pathways leading to them. During synapse formation, the protein localizes to synaptic sites; afterward, it largely disappears. Thus, connectin is a novel cell adhesion molecule whose expression suggests a role in target recognition.

Genome-wide Generation and Systematic Phenotyping of Knockout Mice Reveals New Roles for Many Genes

Summary Mutations in whole organisms are powerful ways of interrogating gene function in a realistic context. We describe a program, the Sanger Institute Mouse Genetics Project, that provides a step toward the aim of knocking out all genes and screening each line for a broad range of traits. We found that hitherto unpublished genes were as likely to reveal phenotypes as known genes, suggesting that novel genes represent a rich resource for investigating the molecular basis of disease. We found many unexpected phenotypes detected only because we screened for them, emphasizing the value of screening all mutants for a wide range of traits. Haploinsufficiency and pleiotropy were both surprisingly common. Forty-two percent of genes were essential for viability, and these were less likely to have a paralog and more likely to contribute to a protein complex than other genes. Phenotypic data and more than 900 mutants are openly available for further analysis. PaperClip

Automated Early Detection of Diabetic Retinopathy

PURPOSE To compare the performance of automated diabetic retinopathy (DR) detection, using the algorithm that won the 2009 Retinopathy Online Challenge Competition in 2009, the Challenge2009, against that of the one currently used in EyeCheck, a large computer-aided early DR detection project. DESIGN Evaluation of diagnostic test or technology. PARTICIPANTS Fundus photographic sets, consisting of 2 fundus images from each eye, were evaluated from 16670 patient visits of 16,670 people with diabetes who had not previously been diagnosed with DR. METHODS The fundus photographic set from each visit was analyzed by a single retinal expert; 793 of the 16,670 sets were classified as containing more than minimal DR (threshold for referral). The outcomes of the 2 algorithmic detectors were applied separately to the dataset and were compared by standard statistical measures. MAIN OUTCOME MEASURES The area under the receiver operating characteristic curve (AUC), a measure of the sensitivity and specificity of DR detection. RESULTS Agreement was high, and examination results indicating more than minimal DR were detected with an AUC of 0.839 by the EyeCheck algorithm and an AUC of 0.821 for the Challenge2009 algorithm, a statistically nonsignificant difference (z-score, 1.91). If either of the algorithms detected DR in combination, the AUC for detection was 0.86, the same as the theoretically expected maximum. At 90% sensitivity, the specificity of the EyeCheck algorithm was 47.7% and that of the Challenge2009 algorithm was 43.6%. CONCLUSIONS Diabetic retinopathy detection algorithms seem to be maturing, and further improvements in detection performance cannot be differentiated from best clinical practices, because the performance of competitive algorithm development now has reached the human intrareader variability limit. Additional validation studies on larger, well-defined, but more diverse populations of patients with diabetes are needed urgently, anticipating cost-effective early detection of DR in millions of people with diabetes to triage those patients who need further care at a time when they have early rather than advanced DR.

Unexpected mutations after CRISPR-Cas9 editing in vivo

To the Editor: CRISPR–Cas9 editing shows promise for correcting disease-causing mutations. For example, in a recent study we used CRISPR-Cas9 for sight restoration in blind rd1 mice by correcting a mutation in the Pde6b gene1. However, concerns persist regarding secondary mutations in regions not targeted by the single guide RNA (sgRNA)2. Algorithms generate likely off-target sites for a given gRNA, but these algorithms may miss mutations. Whole-genome sequencing (WGS) has been used to assess the presence of small insertions and deletions (indels)3 but not to probe for single-nucleotide variants (SNVs) in a whole organism. We performed WGS on a CRISPR–Cas9-edited mouse to identify all off-target mutations and found an unexpectedly high number of SNVs compared with the widely accepted assumption that CRISPR causes mostly indels at regions homologous to the sgRNA. We tested four sgRNAs in cells then chose the sgRNA with the highest activity for in vivo targeting. DNA was isolated from two CRISPR-repaired mice (F03 and F05) and one uncorrected control1. CRISPR–Cas9-treated mice were sequenced at an average depth of 50×, and the control was sequenced at 30×. Variant calls were confirmed by at least 23× sequencing coverage (Supplementary Tables 1 and 2). Multiple variant-calling software pipelines identified indels and SNVs (Fig. 1 and Supplementary Methods). In the CRISPR-treated mice, targeted alleles were repaired1. Off-target mutations were identified as those present in the CRISPR-treated animals but absent in the uncorrected control. All pipelines showed that F03 harbored 164 indels and 1,736 SNVs (63 and 885 of these, respectively, associated with known genes). F05 harbored 128 indels and 1,696 SNVs (51 and 865 of these, respectively, associated with known genes) (Fig. 1). The same 117 indels and 1,397 SNVs were detected in both of the CRISPR-treated mice, which indicated nonrandom targeting. SNVs appeared to slightly favor transitions over transversions (Supplementary Fig. 1). The mutation rate detected in CRISPRtreated mice was substantially higher than that generated by spontaneous germline mutations (3 to 4 indels and 90 to 100 SNVs, de novo, per generation)4,5. As additional controls, each of the variants was compared with the FVB/NJ genome in the mouse dbSNP database (v138), and each of the SNVs was also compared with all 36 strains in the Mouse Genome Project (v3). None of the CRISPR-generated offtarget mutations were found in any of these strains, which further confirmed that these WGS-identified SNVs were the result of CRISPR–Cas9 off targeting. All pipelines identified 6 and 3 indels and 60 and 51 SNVs in F03 and F05 mice, respectively, in exonic regions only (Fig. 1); 5 indels and 24 SNVs caused nonsynonymous mutations in protein-coding sequences (Supplementary Tables 3 and 4). Of these, all five indels and one SNV (introducing a premature stop codon) were expected to be deleterious. Several mutated protein-coding genes were associated with a human and/ or mouse phenotype (Supplementary Tables 3 and 4). Of the 29 coding-sequence variants, 7 variants were mutated identically in both mice. 24 CRISPR-associated variants were selected, and all were confirmed by Sanger sequencing (Supplementary Fig. 2 and Supplementary Methods). Among the top-fifty sequences predicted for off targeting, none were mutated. Additionally, there was poor sequence homology between the sgRNA and sequences near the actual off-target coding and noncoding variants (Supplementary Fig. 3). Our results suggest current in silico modeling cannot predict bona fide off-target sites. Together, these results indicate that at least certain sgRNAs may target loci independently of their target in vivo. The unpredictable generation of these variants is of concern. The impact of the numerous mutations occurring in noncoding RNAs or other regulatory intragenic regions could be detrimental to key cellular processes (Supplementary Fig. 4 and Supplementary Table 5)6. Although our CRISPR-treated mice did not display obvious extraocular phenotypes, it is possible the mice may reveal phenotypes in time, when they are challenged or bred to homozygosity. The present study demonstrates WGS analysis of both indels and SNVs as the most thorough method for identifying off-target mutations and shows a significantly higher number of potentially deleterious CRISPR–Cas9-induced mutations than have been previously reported3. It is not clear whether improved sgRNA

Efficacy and safety of voretigene neparvovec (AAV2-hRPE65v2) in patients with RPE65-mediated inherited retinal dystrophy: a randomised, controlled, open-label, phase 3 trial

BACKGROUND Phase 1 studies have shown potential benefit of gene replacement in RPE65-mediated inherited retinal dystrophy. This phase 3 study assessed the efficacy and safety of voretigene neparvovec in participants whose inherited retinal dystrophy would otherwise progress to complete blindness. METHODS In this open-label, randomised, controlled phase 3 trial done at two sites in the USA, individuals aged 3 years or older with, in each eye, best corrected visual acuity of 20/60 or worse, or visual field less than 20 degrees in any meridian, or both, with confirmed genetic diagnosis of biallelic RPE65 mutations, sufficient viable retina, and ability to perform standardised multi-luminance mobility testing (MLMT) within the luminance range evaluated, were eligible. Participants were randomly assigned (2:1) to intervention or control using a permuted block design, stratified by age (<10 years and ≥10 years) and baseline mobility testing passing level (pass at ≥125 lux vs <125 lux). Graders assessing primary outcome were masked to treatment group. Intervention was bilateral, subretinal injection of 1·5 × 1011 vector genomes of voretigene neparvovec in 0·3 mL total volume. The primary efficacy endpoint was 1-year change in MLMT performance, measuring functional vision at specified light levels. The intention-to-treat (ITT) and modified ITT populations were included in primary and safety analyses. This trial is registered with ClinicalTrials.gov, number NCT00999609, and enrolment is complete. FINDINGS Between Nov 15, 2012, and Nov 21, 2013, 31 individuals were enrolled and randomly assigned to intervention (n=21) or control (n=10). One participant from each group withdrew after consent, before intervention, leaving an mITT population of 20 intervention and nine control participants. At 1 year, mean bilateral MLMT change score was 1·8 (SD 1·1) light levels in the intervention group versus 0·2 (1·0) in the control group (difference of 1·6, 95% CI 0·72-2·41, p=0·0013). 13 (65%) of 20 intervention participants, but no control participants, passed MLMT at the lowest luminance level tested (1 lux), demonstrating maximum possible improvement. No product-related serious adverse events or deleterious immune responses occurred. Two intervention participants, one with a pre-existing complex seizure disorder and another who experienced oral surgery complications, had serious adverse events unrelated to study participation. Most ocular events were mild in severity. INTERPRETATION Voretigene neparvovec gene replacement improved functional vision in RPE65-mediated inherited retinal dystrophy previously medically untreatable. FUNDING Spark Therapeutics.

Mutations in Prickle Orthologs Cause Seizures in Flies, Mice, and Humans

Epilepsy is heritable, yet few causative gene mutations have been identified, and thus far no human epilepsy gene mutations have been found to produce seizures in invertebrates. Here we show that mutations in prickle genes are associated with seizures in humans, mice, and flies. We identified human epilepsy patients with heterozygous mutations in either PRICKLE1 or PRICKLE2. In overexpression assays in zebrafish, prickle mutations resulted in aberrant prickle function. A seizure phenotype was present in the Prickle1-null mutant mouse, two Prickle1 point mutant (missense and nonsense) mice, and a Prickle2-null mutant mouse. Drosophila with prickle mutations displayed seizures that were responsive to anti-epileptic medication, and homozygous mutant embryos showed neuronal defects. These results suggest that prickle mutations have caused seizures throughout evolution.

Precision Medicine: Genetic Repair of Retinitis Pigmentosa in Patient-Derived Stem Cells

Induced pluripotent stem cells (iPSCs) generated from patient fibroblasts could potentially be used as a source of autologous cells for transplantation in retinal disease. Patient-derived iPSCs, however, would still harbor disease-causing mutations. To generate healthy patient-derived cells, mutations might be repaired with new gene-editing technology based on the bacterial system of clustered regularly interspersed short palindromic repeats (CRISPR)/Cas9, thereby yielding grafts that require no patient immunosuppression. We tested whether CRISPR/Cas9 could be used in patient-specific iPSCs to precisely repair an RPGR point mutation that causes X-linked retinitis pigmentosa (XLRP). Fibroblasts cultured from a skin-punch biopsy of an XLRP patient were transduced to produce iPSCs carrying the patient’s c.3070G > T mutation. The iPSCs were transduced with CRISPR guide RNAs, Cas9 endonuclease, and a donor homology template. Despite the gene’s repetitive and GC-rich sequences, 13% of RPGR gene copies showed mutation correction and conversion to the wild-type allele. This is the first report using CRISPR to correct a pathogenic mutation in iPSCs derived from a patient with photoreceptor degeneration. This important proof-of-concept finding supports the development of personalized iPSC-based transplantation therapies for retinal disease.

Intravitreal bevacizumab during pregnancy.

Purpose: To report the clinical course of four women treated with intravitreal bevacizumab during pregnancy. Methods: Observational case series. Results: Four pregnant women were treated with intravitreal bevacizumab for choroidal neovascularization (CNV) because of presumed ocular histoplasmosis syndrome punctate inner choroidopathy, or sarcoid uveitis. Patients received a mean of 2.6 ± 2.3 injections (range, 1-6 injections) while pregnant. One patient was treated with five additional injections while breastfeeding. The mean follow-up duration after the most recent injection was 14 ± 2.9 months (range, 11-18 months). Snellen visual acuity improved in all 4 patients with a mean of 5.75 ± 2.2 lines (range, 3-8 lines). At the most recent follow-up, all patients had involuted CNV that did not require additional treatment. All patients had an uneventful prenatal course and delivered healthy full-term infants. All children have remained healthy, exhibiting normal development and growth during infancy. Conclusion: Offering pregnant patients intravitreal bevacizumab therapy during pregnancy for off-label ocular indications can result in significant visual improvement. No adverse events related to treatment occurred in any patient included in this study. Additional studies with more patients and longer follow-up duration are required to identify any risks associated with treatment.

Disruption of Mouse Cenpj, a Regulator of Centriole Biogenesis, Phenocopies Seckel Syndrome

Disruption of the centromere protein J gene, CENPJ (CPAP, MCPH6, SCKL4), which is a highly conserved and ubiquitiously expressed centrosomal protein, has been associated with primary microcephaly and the microcephalic primordial dwarfism disorder Seckel syndrome. The mechanism by which disruption of CENPJ causes the proportionate, primordial growth failure that is characteristic of Seckel syndrome is unknown. By generating a hypomorphic allele of Cenpj, we have developed a mouse (Cenpjtm/tm) that recapitulates many of the clinical features of Seckel syndrome, including intrauterine dwarfism, microcephaly with memory impairment, ossification defects, and ocular and skeletal abnormalities, thus providing clear confirmation that specific mutations of CENPJ can cause Seckel syndrome. Immunohistochemistry revealed increased levels of DNA damage and apoptosis throughout Cenpjtm/tm embryos and adult mice showed an elevated frequency of micronucleus induction, suggesting that Cenpj-deficiency results in genomic instability. Notably, however, genomic instability was not the result of defective ATR-dependent DNA damage signaling, as is the case for the majority of genes associated with Seckel syndrome. Instead, Cenpjtm/tm embryonic fibroblasts exhibited irregular centriole and centrosome numbers and mono- and multipolar spindles, and many were near-tetraploid with numerical and structural chromosomal abnormalities when compared to passage-matched wild-type cells. Increased cell death due to mitotic failure during embryonic development is likely to contribute to the proportionate dwarfism that is associated with CENPJ-Seckel syndrome.

Combination Therapy for Neovascular Age-related Macular Degeneration Refractory to Anti-Vascular Endothelial Growth Factor Agents

OBJECTIVE To examine the outcomes of combination anti-vascular endothelial growth factor (VEGF) and photodynamic therapy (PDT) for the treatment of neovascular age-related macular degeneration (AMD) refractory to anti-VEGF monotherapy. DESIGN Retrospective, interventional case series. PARTICIPANTS Twenty-six eyes of 26 patients treated with anti-VEGF monotherapy for neovascular AMD with persistent subretinal or intraretinal fluid after at least 3 anti-VEGF injections in the 7 months before combination treatment. INTERVENTION Combination anti-VEGF treatment and PDT. MAIN OUTCOME MEASURES Visual acuity at 1 or 2, 3, and 6 months and central retinal thickness at 1 or 2, 3, and 6 months. Secondary outcome measures were change in number of fluid-free visits and interval between treatments in the 7 months before and 6 months after combination therapy. RESULTS Statistically significant improvements in logarithm of the minimum angle of resolution visual acuities were present at 1 month (P = 0.01) and 3 months (P = 0.01). Significant decreases in central subfield retinal thickness on optic coherence tomography (OCT) were seen at 1 month (P = 4×10(-5)), 3 months (P = 3×10(-4)), and 6 months (P = 4×10(-5)) as compared with precombination treatment OCT scans. The percentage of patient visits with no subretinal fluid increased from 0.5% to 41% after the initiation of combination therapy (P = 1×10(-5)). The interval between treatments increased from once every 1.6 months in the 7 months before combination treatment to once every 2.7 months in the 6 months after combination treatment (P = 0.002). No ocular complications attributable to PDT were seen. CONCLUSIONS Rescue therapy with the combination of anti-VEGF and PDT in eyes that have failed anti-VEGF monotherapy resulted in a mean improvement in vision, a decreased central subfield retinal thickness, and an increase in fluid-free intervals. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.