 My name is Tata Steven Tseng, I'm a graduate university student. Steven has a long career in Gino engineering and he's an expert in stem cells. He was active in the photo-technology firm in the early 1990s. He was one of the first to produce knockouts, most knockouts. A particular topic was the PDE gamma knockout. PDE gamma has been in many of you probably don't know. It's an inhibitor and its knockout actually decreased the activity of PDE which was a very surprising result in the 20s. So here, Steven Tseng is an expert in many, many different topics. CRISPR-S9, viral vectors, proteomics, invasive imaging, gene therapy. So he's a really versatile clinician-scientist and he's giving a presentation today on gene-typing of patients without high CTX10, which is a whole genome sequencing method. All right, Steve, looking forward to your talk. Thank you Wolfgang for the generous introduction and also thank you for the opportunity to visit the Moraine Eye Center. So for the residents and fellows, this is a clinical case presentation similar to the Foresting Conference, how I guess Paul and I learned it at the Georgetown Foresting Conference style. So just imagine that you are in a busy morning clinic. So every time you see a picture of Columbia, that means that there's a new patient walking to your office. So advertise that we have anybody interested in genome engineering on Saturday before Apple, mostly by people that know a lot more than I do, but from Bruce Cochran and Howie Wang, they hold a record in terms of engineering IPS efficiency and Howie Wang in terms of nobody can do CRISPR, but knocking in mouse oversight for more than 4KB. So they still hold a record. So to summarize, in case you need to get paged out, you get paged out during the case presentations, this is the summary. So I have inquired in ophthalmology, you can, at beginning residents, you should feel fortunate in this part of medicine that you can look at the patient and you know except what nucleotide change the patient has. Just by clinical examination, you do not need to do sequencing. Sequencing is just for confirmation. And I posed this question to Victor McCusick that what are the areas in internal medicine that you can look at the patient and know what the nucleotide change, just by clinical examination alone. And he can come up with the acondiplation, so 99% of patients, if you make a clinical diagnosis of acondiplation, it's going to have this 380 residue change in the fiber growth factor receptor 3. In posterior, you make a diagnosis of posterior, 80% of the patient is going to have this mutation in the laminin aging in the 1824 residue. And then there's some conditions, but in ophthalmology, I'll show you that the more than a dozen conditions in the retina, you can look at the patient, you know what residue the patient has. Sometimes you can look at the patient, you do not know what residue, but you can narrow down what gene it is. For example, you make a diagnosis of congenital fibrosis, you know that this is going to keep 21A gene. The list is growing, the number of genes causing RP, so I try to convince you that you do. In the East Coast patients get consultation in many different clinics. In Boston, they seem to like DNA sequencing, exome sequencing as a primary technique to make a diagnosis. I'll tell you that maybe you can be more cost-efficient. Just look at the patient first. Do a few candidate genes before you do to hold genome or hold exome sequencing. The reason we need to know the gene is because many times now we had better genotype phenotype correlationships, then we can now give a patient a prognosis, and of course this is important for family genetic counseling, pre-symptomatic counseling, or carer detection. And most likely in the next two decades, gene therapy, gene specific, so you need to know the gene before gene therapy can be applied. As we know more and more about the phenotype, then we can correlate with genotype and they can go back and inform us what kind of phenotype we expect when a patient has certain genotype and vice versa. For the beginning resident, we will do a couple of imaging techniques to help us to discern the genotype just by in the clinic. Typically, if you use the government program, IGN, to do DNA testing, you may take four years before you get results. So for now, a lot of times you can look at the patient, you can give the patient results at the end of the day. So this is all the fluorescent imaging. We are focused on some of the work done by Janice Barrow. We do quite a lot of all the fluorescent imaging. This is very free. This is how the fundoscopy looks like, and this is infrared. So the first patient comes to the consultation. Who has the pointer? Okay, you can describe. So if a patient comes to the consultation, they want to know whether or not they want to take vitamins. This is the fundoscopy picture. So there is a yellowish coloration. So if a patient wants to know whether or not he should be taking vitamins. So with autophoresis imaging, would it help? And this is a very characteristic pattern. It gives a petaloid, like a covalent kind of atrophy. The punctate hyperphoresis. The bullseye is an actinopathy. So bullseye by definition has to be a continuous atrophy. So the atrophy has to join each other. Unlike what the bullseye manual wrote, this is not exactly bullseye atrophy. Bullseye has to be a continuous atrophy by definition. So this is kind of a little spotty. And the atrophy, they don't join each other. So by bullseye, they join each other. So in the clinic, sometimes we need to look at other family members. So the daughter came with the father as a symptomatic. Do you want to describe the picture? 2015 vision for the daughter, the right eye. There is some... And the left eye. So autophoresis helps to discern. This is a symptomatic daughter, 2015 vision. You can also see this kind of spic code, hyperphoresis around the area. So we generally do electro-diagnostic, and ERG testing was normal. So this is actually a... This will be sufficient to tell the resident. So any suggestion, what condition first? You remember the paper, then this is what the cathartic phenotype described by Adam Bird and Tony Moore. At least the diagnosis, the name of the conditions. What's most likely, though? This is very cathartic, the spic code type for us and the cobalt leaf type of pattern atrophy. The gene was described by a neurologist. Unfortunately. Not by an automologist. So this is a... The residue is 172 of the LDS. So this is very cathartic. You can see this sort of a... Puntate all of the hyperphoresis and with a cobalt leaf type of pattern atrophy. This is an LDS periferant. So this is a form of pattern macrodistrophy. And in this case, it's very specific to this 172 residue. I'm not sure why, but this is how... All the patients with this 172 residue will show up at this... But this residue gives very specific phenotype. So a different patient, you can pass your pointer to your neighbor. Another patient came for a consultation. 2424 division. It's a fundus picture. And then you need to notice that there is a drusen on nasal side or this. Anybody want to describe this picture? Yeah, so nasal side is very cathartic. So most of the time you don't see drusen on nasal side. On the disc. And it looks like they're drusen or drusen loin. And some yellowish discoloration. Hi, I'm Agon. How do you describe this pattern of drusen? But that's not so cathartic. But the cathartic one is the one on the disc. But what do you call this kind of drusen? Yeah, both eyes are nasal. So on the disc. It's just diagnostic for this condition. And you should maybe even know the residue of the gene. So I'm not sure the exact word that you used to describe this pattern. But it's kind of almost stellate or projecting out. Yeah, so kind of... It's called radio, by the way. Radio. You can see that on the disc. So usually AMD drusen, usually do not hyperphorest. For some reason drusen are associated with macaditrophy. They tend to hyperphorest very well. And all the fluorescent imaging. I think we'll see. Maybe you can dim the lights in the front. You'll see a little bit better. This is infrared, higher mac. You can see kind of the radio pattern. These are the OCT. These are all the drusen loin deposits. Right eye, left eye. You can get some tubulation also. Does anybody want to suggest? Yes. Very good, very good. In Europe, they call it malatia. In Europe. In the Anglo-Saxon speaking world, then it's called Dorian centricone, described by professor Dorian Oxford. But in Europe, because of the... This is a Swiss-Italian valley. So they all have this mutation in this fibrillant... I think a fibrillant 5-gene, EGF-containing fibrillant-like exosalem matrix motif. And everybody is going to have this 345-residue, with this mutation. So a different patient drusen on nasal side of the disc. We even have two families in Washington Heights in Manhattan. So sometimes their family do not know and they're somehow originated from Switzerland. But they have a big pedigree in Iowa and also a big pedigree around Oxford, where professor Dorian had worked. And it's the most one to be made. Yes, so the knock-in mice in a single allele has almost no phenotype. Only the double dominant has a phenotype. Double dominant. So in patients, it's dominant, one allele. In mice, you need two allele to see phenotype. So this is just another patient. You can see... I think this one is actually from Washington. She lives around Washington Heights in uptown Manhattan. So you see drusen on nasal side of the disc also. Of course, around the drusen, you get a little bit of decreased sensitivity on micropermitry testing. So now you can pass on, point it to another different patient. This one, actually, I took it from the internet, from some grand rounds case, but I do not agree with the diagnosis of someone posted their grand rounds on the website. So the patient came for diabetic screening. That's very typical. This patient usually comes for diabetic screening. Vision is excellent. Every time... This is not my patient. This is taken from somebody else's grand round. But this patient, typically, they don't know why when they come to the eye clinic that there's a long line of residents and fellow want to look at them. And the vision is very excellent, 20-20, usually. Do you want to describe this patient? So this is a forest. In the context of time, I went through the foresting quickly. Yeah. So this is a classic presentation of something called a window defect for the resident. When the RPE is gone, the window, you can see the coroid RPE window. So in the list of the... somebody else's grand round presentation, they post it on the web. These are the differential diagnosis that they offer. But I don't agree with any one of them, though. So this... And then this is one of my patients. You can want to describe it. I think they have the same diagnosis. Although I cannot genotype the patient from the Internet. But I think they have the same diagnosis. Yeah. Yeah, there's a name for this also. There's a name for this kind of pathometrophy. The right eye, the left eye. So it's kind of the mid-face of the foresting. Just want to show you at the end... So the system also has some similar problem. So when you describe this, this is all the forest imaging. So usually for the resident, you wait a minute, maybe five more years later, the area, the hyperphoresis, will be the area that's going to have atrophy, usually. It kind of suggests where the future atrophy is going to be. Hyperphoresis. So it's also spared the centrophobia in this patient also. There's another patient with the same condition. So it's also trying to spare the centrophobia in the left eye. And also for these deposits on the nasal side, also this is also not quite common in terms of other kinds of genes. But for this one, it's more common. Does anybody want to suggest what this is? What the patient has? We can see a couple more cases, though. I guess we saw this one already. This is maternal inherited diabetes and deafness. So this is called annual atrophy. It's spared the centrophobia. Usually they come for that. It's not uncommon that maybe 5% of patients that come through diabetic screening, they have this. But they are usually asymptomatic. They would not develop hemorrhages. They would not develop the proliferative diabetic retinopathy. So the problem is this is in the mitochondria. So sometimes it may or may not because of the threshold effect. It depends on the number of mutations in the retina, the number of mutations in the cochlea, the number of mutations in the pancreas. They may not all have hearing loss and they may not all have retina finding. But you make a diagnosis. Normally we have this 3, 2, 4, 3 residue in the tRNA losing gene. Sometimes this mitochondrial DNA sometimes is difficult to capture by whole exome sequencing. So you send a patient for whole exome sequencing, you may miss it. Unless you tell the lab you're looking for mitochondrial DNA. So the whole exome sequencing for clear testing costs about $6,000. If you just do one residue, it's going to be less than $100, maybe like $40. So it's a little more cost efficient. But some reason in Boston they like to do whole exome sequencing. Is the speed of the mitochondrial stay intact? No, a long time. Maybe it's 70, 70 years old and fovea fat macros stay intact. This is called annular atrophy by the way. This is called annular atrophy. This is a patient referred to me by John Flint. I'm going to describe this. What do you think of the nerve? What about outside the nerve? Pericaptor. Yeah, pericaptor. There's a right eye and there's a left eye. This is a three-year-old child. So notice how to describe the shape of the atrophy. Maybe it's easy to see on infrared and autofluorescent. So I want to note to you that infrared imaging goes more deeper to the chloride. So you can see that this is a loss of chloride. Autofluorescent mostly is from the retinopigmented epithelium, RPE. This is actually quite intact on the RPE. And that gives you a clue of where the gene is supposed to express. So this gene probably initially affects the chloride before the RPE. OCT is not too special. So in the context of time, I'll go through that quickly other than just a loss of RPE. So the patient was sending this. This could be a toxel. So anybody agree? Toxoplasmosis. We can look at the mother first. Mothers say it's symptomatic. They're from New Jersey, though. They're from New Jersey. But typically it's more common in certain parts of the world. I'll tell you where later. The patients from New Jersey. The right eye, left eye. You want to just describe the left eye? I need to point out the differential diagnosis. There's no cells in the vitreous in this patient at all. They involve the child and the mother. And grandma, associate grandma later. This is still the mom. So this will radiate up the white area, the hyperforestation area. It will be the future part of the goniatrophy. So these patients, maybe by the time they're 80, they will affect the fovea. But typically it's symptomatic. Left eye. You can see that there's some names for this, though. They term the radios up. So lots of RPE. You can see the Colorado shadowing much better. So we did electro-diagnostic also. Electro-diagnostic is pretty normal. Both mom and grandmother. Grandmother looks the same also. We saw grandmother. Does anybody want to suggest what this could be? It's more common in Iceland. But the parents, the patients from New Jersey, it's more common in Iceland. There's many different names for this condition, though. The reason I brought this case up, because in the Grand Rounds presentation from the internet, they said their case could be atrophic areata. But the diagnosis for these patients is atrophic areata. There's one of the names, but they have other names also. We also call the circumperiority this genesis of the pigment epithelium. I think this is a misnomer, and I'll show it to you that this is not a pigment epithelial disease. This is probably a Colorado disease. So there's another name. It's called horticoidal peripapylchloro-retinoid degeneration. There's no cells in the vitreous, and the patients are young, but it's on a differential. You need to consider that as a pigeoness because of the tongue-like lesions radiating out from the disc. So I think this is a... We take donor eye bank, and also one is from the mouse. I think this is from the eye bank, and this is from the mouse. Looking at antibody to this gene, this is a transcription factor called T-net, T-net1. This transcription factor is not found in the RPE. So this is a misnomer. So it cannot be a disgenesis of the pigment epithelium. And then another fluorescent imaging, I showed to you earlier that the RPE looks intact in the child, but it's expressed high in the chloride and no sensory retina, also expressed in the muscle. Also, this is from the mouse, and this is from human, from eye bank, so it's not in the RPE. It's found in the chloride. So this time, I'll give you a clue where the patient comes from. And they will give you the gene kind of... because this is not found in other ethnic groups. So typically, they don't have symptoms until they're close to 60. And the name for this condition contains this feature. You look at the periphery. So the pigment are deep, so they don't have pigment migration. Typically, photoreceptive disease, you will get pigment migration. This one don't have much pigment migration. The pigment are kind of deep. You cannot tell unless you do with a 90-day after-lens, so there's not much pigment migration. The pigment are kind of deep in the RPE level. So this is a typical scarlet type of atrophy. So for Randy, I bought an anterior segment photo. So what do you think of the lens? So the problem is that in New York, at the time, these patients are pseudo-fake already. So it's very difficult. But this one, at least, you can see the... So what do you think of the lens? What do you think of the residents? The lens. So what are those? No. So it's probably going to be more kind of like cloudy, right? Yes. Yeah, zoners are inserted quite anteriorly. In combination with this fundus photofinding, anybody have a diagnosis? Yeah, that's on a different show. It's very good. Yeah, why would there be a color difference? I'm not asking the residents why. It was on the first slide. Yes. His father was... Yeah, so that should not be a great remand. I will show you that. Yeah, it could be. It would be a very high end differential. Yes. What are the conditions you get this zoners inserted so anteriorly? So these are autofluorescent imaging. It just shows highlight the center. Now you see corridor autofluorescent. Corridor autofluorescent. So this is called LOD, late onset retinal degeneration. And once you make a diagnosis of LOD, this is dominant, then you know that everybody is going to have this 163 residue in the CTRP5 gene. The gene is still unknown, but it dimerize with another interesting gene that I'll talk about this afternoon, which is an infrasurative-related protein. So the onset is quite late for this patient, so they are not symptoms until almost in the 60s. And it behaves like retinitis paymentosa. They typically have complain of nectonopia. And this is the peripheral finding that can look like caudoremia, or gerid, as Paul pointed out. So this is quite... I think maybe... the condition gives you this kind of insertion or lenson interior. So today is another one. You can look at the patient and you know what residue. Without sequencing. If you want to get a diagnosis. So this is just a distinguishing caudoremia. But the... at least the caudinitis may have some more of this bridging. Sometimes it gets this bridging type of preservation. More common than late onset retinal degeneration. We'll skip through this. So now we... As I've gone over with you, at least for this part, you can look at the patient and you know what residue. So if you think of diagnosis of this punctate, spiccote, ring odour fluorescent, and then with scallops atrophy in the center, this is most likely to be LDS peripheral 172. Actually, in cases, this is more common in Iceland. But my patient came from New Jersey. And then you get... this transcription factor is 421, once you make a diagnosis of atrophic areata. The other name is called Stevenson's caureo-retinal atrophy. I'll show you an example of a maternal inherited diabetes and deathness. Once you make the diagnosis, you know that this is a 3-2-4-3 residue in this T-aluminate losing gene. During honeycomb, once you make a diagnosis, you know that it's going to be fibrillant 3,345. Late onset retinal atrophy they just show you the CTRP5 gene. I didn't have time to show you most cases of sector RP in this country. It's going to be Rodoxin protein HIST-23. But now we're going to have some genes. We can look at the patient. You do not know residue, but at least you can have which gene? I'll show it to you. So there would be something similar to congenital fibrosis. Once you make the diagnosis of congenital fibrosis in Taiwan, you know that this is canizine KIF-21 aging. So this child is from Greece, came for consultation. He has loaded lots of steroid before I saw him. Vision continued to drop and loaded lots of steroid with no improvement. Vision become worse and worse. Want to describe this? This particular condition like to affect the vessel more than the other forms of retinal degeneration. You can see some exodate at the periphery. This is what we call colts like response. I'll show you some photos in picture later. You can see some leakage at the periphery. In the context of time, I wanted to show you the most permanent finding. So how to describe this? I'll show you the time later sequence. For some reason, not all the photos have popped up or show up. Anyway, there are some extensive leakage at the periphery but not all the, for some reason, not all the photos in frame show up. So the most important one maybe this may not be the best one. There's a left eye both are the same. So what do you call this? This is this is a vein or artery. Maybe I have some better picture. So some reason not all the pictures I see on my computer didn't show up on the screen. So this is I tell you this is an artery and this is a vein. So what do you call this feature? This may be a better one. So this is an artery and this is a vein. There's some leakage. I'll show you the imaging. Okay. So what do you call this? This is an artery. So this is all for us imaging this is an artery and these are veins. This is a different patient by the way. But this patient cooperate better so we can get better all for us imaging. And the other feature is that what do you think of the retina on OCT? So I can tell you this was described by John Hecker Lively and this feature was described by Sam Jacobson. So in the combination of this you should know the gene. So steroid steroid did not help because it came from the uveitis clinic. The referral in this patient. And then this is I think this is also a different patient. It's very common to have the demon also to this group of conditions and then you also see the arteries are more spared compared to the vein. Maybe I made some more pictures. It shows that it's easier for us imaging. So the veins are the RP around the veins are affected but the RP around the arterios are not affected. So right eye, the left eye. So the veins are affected RP and the arterios are not affected. So there's no other gene will give you this kind of gene feature. Any suggestion? What gene to this be? What do you think the most likely diagnosis first? So this is a cold side response with peripheral ischemia in this patient. The one from the uveitis clinic. This will be on the differential diagnosis but this is a CRB1 crumbs. So a lot of the colds response in patients with retinitis paymentals that they turn out a mutation in the patient. So Sam Jacobson described the inner retina get thickened but in this condition with the CRB1 gene is the gene is probably more often retinal organization but I don't know why they get the paraterios bearing. They have mutation in CRB1. Usually typically not, don't have deafness though. CRB1. So this is a found in the fly. Probably in some kind of epithelial cell junction development in the fly. But in the context of time I skip you through the biology of CRB1. So you can also cause our people can also cause labors, congenital amaurosis depends on the mutation. So the cotton official use power arterios bearing described by John Lively. The power arterios bearing. She likes to have coats like response. It was said that it can cause pyrovenous RP but I screen all my pyrovenous patients but they don't have a CRB1 mutation. But that's in the literature. No, the CRB1 was described but I think that one is just a SNP so we cannot find any mutation in CRB1 in pyrovenous RP. So now we just diverge a little bit to show you the labors and as a segment to labors and I go through them quickly because there's one more case at the end. This is in the, I think it's the MoMA Metropolitan Museum. So this is probably a patient of labors. They rub the eye. So the orbital fat atrophy Picasso painting. Typically we at least we try to do skin electrode. We learn it from Graham Holder and Dorothy Thompson they do skin electrode for labors so they are pretty extinguished. And also in the context of time I would not tell you too much about the biology of different genus. Just try to show you the phenotype. Maybe so these are my limited experience. Maybe also maybe Paul can chime in and see this is a constant phenotype. This is a CEP 290. Quite early one they have a central atrophy and sometimes younger patient you have dots. So CEP 290, yellow dots in the peripheral retina. CEP 290 formal labors. Sometimes they come with jovial syndrome but sometimes just CEP 290. So these are babies with labors extinguished ERG. Cyclase one of used to be Wolfgang most favorite gene but maybe not anymore. Cyclase typically have a normal fundus. So ERG is complete extinguished with a normal looking fundus in the baby. Cyclase would be very high in your differential. They are very photophobic as opposed to some other gene that I'll show you for cyclase. When they get older they get a bit atrophy, sort of pathotrophy in the peripheral retina. That would be a more typical form of cyclase presentation. Some cyclase patients can be severe to get a central atrophy but typically the fundus can be normal. I show you the phenotype for CRB1 already. CRX is a transcription factor in embryogenesis. They usually have a funny looking fovea. Maybe it's only some better picture. They were more typical of a funny looking fovea development or macro development for CRX. This is probably the only form of labors early onset retinal dystrophy that are dominant or the other ones are recessive. Skip through RP65 quickly in the context of time. RP65 the resident and fellows need to know because this one gene therapy is being done. This is probably the only one together with LRAD that you do not have fundus autophoresis. This is another one you can look at the patient you know what gene it is. All the other forms of labors have early onset retinal dystrophy would have autophoresis. RP65 and LRAD and LRAD is so rare I don't have seen any. Do you have any LRAD patients here? In fact we don't even have any RP65. So the typical description of RP65 are soft and pepper retinopathy absence of fundus autophoresis and they like to stare at light as opposed to cyclase. The cyclase patient are rare photophobic and this patient they like to stare at light. We eventually get some atrophy but this is the classic soft and pepper retinopathy that you see in RP65 and just show you another patient is soft and pepper retinopathy. You can skip through the the gene there. When you get older they just look like any other kind of RP patient when you get older for RP65. So just show you the classic soft and pepper retinopathy. RDAX-12 is also very cathartic phenotype. In addition to A, B, C, A4 I didn't show you any for STAGA your peripeptus bearing of the RP. RP around the nerve is not affected and it is kind of numeral round atrophy. I don't know why but this is very cathartic for RDX-12 retinopathy hydrogenase and you can see this kind of macular phenotype. There's no other gene will give you this kind of very round numeral atrophy around the macular. So a different patient you can see that the central macular finding is very cathartic for RDX-12 and I think this is a gene that Robin Ali and Dorothy Thompson also try to bring it to human treatment trial. The peripheral fundage is not so specific but the macular phenotype is very specific together with peripeptus bearing of the RP. This is another patient so you get this kind of numeral round pigment in the center. ARPR-1 this is a chaperone protein in folding the phosphodiesterase. So very severe. They get a pretty much a central atrophy very early on as a newborn baby. And the retrophy is not just over time. Let's get through this. RPGR grip is not so specific but you get this a lot of pigment quite early on as a baby. I want to go through at least one more interesting case. There may be two, I can pass your pointer, there are two more cases before the hour. So this is from our neighborhood. We have more people that live in Washington Heights from the Dominican Republic than in the Dominican Republic. So every time they election for president all these booths set up around Washington Heights. So we did some foresting at that point. Yeah, just the same patient, just window defect, a lot of part of the retina. So I will confess at this point she came back, she came back. And this is a fundus finding. Is anybody? Same patient. Fairly preserved, the Mac, I would say. You just look at this, it's very sharp. Yeah, and then the left eye. Peripheral retina. And then we have a different patient also in Washington Heights that wants to show you how the autofluorescent looks like. So what tests will you do next for this patient? There's very few treatable forms for retinal degeneration so residents should know. Well, what kind? So the problem is that every time I order this test in New York Pasadena hospital they don't know how to do it. That's the problem. I need to go back a couple of times and tell them I don't want the full panel. Very good. So you can... Yeah, they're very serious and this is gyrate atrophy and if you patient are complying with this diet I haven't tried it myself but I heard they taste like cardboard. But if patient are complying with this diet they completely will stop the degeneration. This is one of the few that we can treat. This is a quick case, intermission before the last interesting case that I want to suggest. It will be easier if I tell you this patient came from the dermatology clinic. The right eye. Left eye. He came from dermatology. So he's a young girl. What do you think of this? He came from dermatology clinic. So this is a Puder Ranch. Puder Ranch. This is an interesting patient that I share also with people in Boston when they describe the fundus. This will be the last case before your hour. More periphery. Left eye. What level do you think this lesion is? What level? In the retina. What level? You talk periphery also. So what do you think happened before in the right eye? In a child, in a young child 16 years old. So for the resident Coretone vascularization in a child there's a limited number of differential. I can tell you this is what this is not. You need to consider best for Coretone vascularization in a child sometimes so speak. But this patient does not have those. Trauma. Coretone vascularization in a child. This is the other differential for that. Not in children though I think. So do you see all these? Left eye. You can do OCT finding though. So what do you consider this in OCT? I think this corresponds to the white dots. I think these are photoreceptors actually. So this patient actually already been to Boston before he came to New York to see me. So they have a lot of work up in Boston. And then finally we did the ERG in New York. And of course a textbook writer said that the patient have bilateral dosen. Bialateral dosen. Dosen is Diffused Ural Neural Retinitis. Diffused Ural Retinitis Diffused Ural Retinitis Diffused Ural Retinitis and the diagnosis from Boston was bilateral dosen. Bilateral. So this was the diagnosis from a textbook writer. So we did the ERG in New York. So the normal trace is down right here. The normal trace. So this is the rota extinguished. As you can see here in the child. And the cone has a special shape. Usually the shape of the maximal ERG is very different from the shape of the single flash cone ERG. This is a 30-hertz flicker. And also notice another feature. Usually the A-wave for single flash is quite small. And this way it's smaller than the 30 hertz. In this patient this A-wave is bigger than the 30 hertz. And there's no other gene will give you this feature. What's described by, I can tell you maybe it will help the clue. Well first described by Mike Marmer and Peter Goros. The ERG feature. This is the rota extinguished. So the shape looks very similar to a single flash. Yes. You should give the resident a chance. Okay, I'll go through this quickly. So usually the A-wave normally is smaller than the 30 hertz flicker as I've shown previously. So this is normal. A-wave is much smaller than the 30 hertz. But in this patient the A-wave is bigger than the 30 hertz flicker. This is a normal situation and this is our patients. So this official enhanced S-con. And then the we don't have a lot of S-con control from just standard ERG is enough to make a diagnosis for icing in the cake with the S-con ERG. But we don't have a lot of control for children. So a fellow, one tier his son of the S-con ERG. So this is his son. And this is our patient. So this is enhanced S-con. So typically the rod responses are completely extinguished. The patient no rod. Usually I tell the children that you have enhanced S-con syndrome your retina looks like a dinosaur's retina. Dinosaur's retina don't have any rods. And this patient has a homozygous mutation in this transcription factor. And now to E3. Homozygous. So you should be able to in older patient. I'll show you the picture. The fundus is more characteristic in older patient. They have nominular pigment around the arcade. And then there's something new is here that we found that they have this kind of retina rosettes. Showing you in here. Let's go and skip through this. So in mice you get this kind of rosettes in enhanced S-con RD7 mouse. They get also white dots also in mice. So you get this folded rosette. And it looks like the same as our patient. So the patient have the let's see. So this I think interpreted as the same kind of rosette. You saw it as in this is a mouse retina. When they get older they become flatter degenerate. So these are actual macrophages. There's little dots here. And then the round ones are rosettes in the mouse. These are typically round pigment and the level of pigment is at the RP level. They don't have pigment migration. Let's see some more. RP patients typically have a high density ring and in enhanced S-con you get kind of a amorphous ring in the macular. And also RP patients you don't get ring on the nasal side in enhanced S-con. You also got on the nasal side also in the retina. So with some other pictures in enhanced S-con this is an older patient. You get this round luminal pigment. So these are very round and they're sub-retinal. Most of the patients with retinitis pigment have sharp edges and most of the pigment are intra-retinal. But in enhanced S-con these patients are sub-retinal. Sometime on the referral letter they said that other patients don't have diabetes but the comprehensive ophthalmologist will write that they don't accept a patient got PRP scars but they don't have diabetes. They don't know why. So they send a patient in. So typically because you don't have enhanced S-con the transcription factor is required to convert to push the cone fate into rods so you don't have the transcription factor for the enhanced S-con gene or your retina become cones and there's no rod and that's why they are night blind. It's the same gene as Gorman-Farré syndrome. Eventually they get a lot of vitreous changes and it gets gaises. So this is just the same gene. A 9-tascone Gorman-Farré. I'll go to the conclusion slide. Let's see. So just looking, I'll show you examples this morning. Just looking at the patient. In many cases you can just look at the patient, you know what resident. So ophthalmology is unusual compared to medicine because in internal medicine you can only meet a victim can only find out two conditions. Acontroplasia. Every patient with acontroplasia pretty much is going to have a mutation in the 380 residue for the fibroblast growth factor receptor 3. You make a diagnosis of progeria then you're going to know the patient is going to have a mutation in the laminate A gene in 1824 residue. In other cases including a lot of disorder, you look at the patient in combination with imaging in actual diagnostic testing you cannot tell which residue but you can tell which gene. So doing one single gene testing it took you like $200 clear testing. Whole exome sequencing, clear testing will typically cost you like $6,000. So now you can help you to target DNA screening instead of just doing whole genome sequencing. Knowing the gene give patient better prognosis allow pre-symptomatic testing and carrier detection and this all this is because in the future gene therapy will actually be gene specific. And then also we can now determine what gene even with pharmacological treatment then maybe we can determine what gene that would be more treatable. And so we learn more and more that we can get better genotype and phenotype correlationship. Genes can cause retinal degeneration I'll show you in the case of pattern macrodistrophy make the diagnosis with the spit code order for us. You know there's going to be LDS periferin at the 172 residue at trophic areata it's going to be the T net gene 421 residue maternally inherited diabetes and deafness it's going to be the TRNA losing gene the mitochondrial 3243 residue Doin honeycomb malatia is going to be fibrillin 3 345 residue late onset retinal degeneration is going to be CTRP5 gene and in the other cases you can tell what gene and you can focus your screening. So this is one of the ophthalmology one of the few areas in medicine you can look at the patient and you can tell what gene I suppose a lot of the in pediatrics and in neurology they're moving toward whole exome genome sequencing as a diagnostic primary diagnostic too because when they look at the patient they cannot tell what gene the patient got but in ophthalmology most many cases we can tell the patient what gene so we can focus your gene screening that's why you can start doing genotyping in your own clinic this afternoon Everybody's invited we have a course in January we have about 60 residents from all over the country and different people have come and teach our course in January we have Dr. Japs, Marco Peter Goros Don DeMico come to teach Graham Holder, Yajik Joe Deema, Ralph Eagle Alan comes to teach in January Larry teach also Tom Sakma even Mike Woodruff came all the speakers are based on cost evaluation the resident did not like photo transduction so we didn't have that we didn't have Tom Sakma and Mike Woodruff came back to teach anymore all of us SACs used to teach also, Andy Lee Tony Moore and Irene Momely also came to teach he deserve an angle also came to teach our course Ian McDonald to return for your hospitality all the residents and fellows they invited to come also to our course in January Thank you Any questions? I'd like to ask a question How about I think those students that you presented are really nice and that there is like a great relationship what about those students for example the pattern of this how do you compare your thoughts on that so we always look at the family because your differential sometimes there is some overlap between Stargard and Pedestrian so look at the family first to see if this establishes dominant or recessive and then you do the most likely gene first which is LDS is this negative you can consider do a retina panel if there is still negative whole exome sequencing or whole genome sequencing as a backup but there are still cases there with with whole exome sequencing we can now probably solve about 80% of our cases though so the whole exome sequencing depend on insurance New York New Jersey Blue Cross Blue Shield you can get them done pretty easily Aetna is quite difficult to get whole exome sequencing done but the National Health Service the National Health Care is offering whole genome sequencing as a pilot study for 100,000 patients and many of the more fused patients already gotten the whole genome sequencing already so sometimes national health care can be good I think in Germany also do a lot of whole exome sequencing also covered by private insurance Thank you