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Stargardt disease

(Redirected fromStargardt's disease)

Stargardt diseaseis the most common inherited single-generetinal disease.[1]In terms of the first description of the disease,[2]it follows anautosomal recessiveinheritance pattern, which has been later linked to bi-allelicABCA4gene variants (STGD1). However, there are Stargardt-like diseases with mimicking phenotypes that are referred to as STGD3 and STGD4, and have aautosomal dominantinheritance due to defects withELOVL4orPROM1genes, respectively. It is characterized bymacular degenerationthat begins in childhood, adolescence or adulthood, resulting in progressive loss of vision.[3]

Stargardt disease
Other namesStargardt macular dystrophy & degeneration, juvenile macular degeneration, fundus flavimaculatus
Optical coherence tomographyis used for diagnosis of Stargardt's disease.
SpecialtyOphthalmology
SymptomsLoss of central vision, low visual acuity
Usual onsetChildhood
DurationLifelong
CausesGenetic
Diagnostic methodSlit lamp
TreatmentNone

Signs and symptoms

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The presentation usually occurs in childhood or adolescence, though there is no upper age limit for presentation and late-onset is possible. The main symptom is loss of visual acuity, uncorrectable with glasses. This manifests as the lack of the ability to see fine details when reading or viewing distant objects. Symptoms typically develop before age 20 (median age of onset: ~17 years old),[4]and include: wavy vision,blind spots,blurriness,loss of depth perception,sensitivity to glare,impaired colour vision,[4]anddifficulty adapting to dim lighting(delayed dark adaptation). There is a wide variation between individuals in the symptoms experienced as well as the rate of deterioration in vision. Vision loss can be attributed to buildup of byproducts of vitamin A in photoreceptor cells andPeripheral visionis usually less affected than fine, central (foveal) vision.[citation needed]

Genetics

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Historically from Stargardt's first description of his eponymous disease until recently, the diagnosis was based on looking at thephenotypeusing examination and investigation of the eye. Since the advent ofgenetic testing,the picture has become more complex. What was thought to be one disease is, in fact, probably at least three different diseases, each related to a different genetic change. Therefore it is currently a little confusing to define what Stargardt's disease is. Stargardt disease (STGD1) is caused by bi-allelic ABCA4 gene variants (i.e., autosomal recessive). Importantly, the exact genotype (i.e., combinations of both ABCA4 variants along with the presence of additional genetic modifiers[5]) is highly prognostic for the age of onset and disease progression.[6][7][8][9]

Autosomal-dominant Stargardt-like diseases were linked to genes such as PROM1 (STGD3) or ELOVL4 (STGD4)missense mutationsplay a role remains to be seen.[citation needed]

The carrier frequency in the general population of ABCA4 alleles is 5 to 10%.[10]Different combinations of ABCA4 genes will result in widely different age of onset and retinal pathology. The severity of the disease is inversely proportional to ABCA4 function and it is thought that ABCA4 related disease has a role to play in other diseases such as retinitis pigmentosa, cone-rod dystrophies and age-related macular degeneration (AMD).[11]

  • STGD1: By far the most common form of Stargardt disease is therecessiveform caused by mutations in theABCA4gene.[12]
  • STGD4: A raredominantdefect in the PROM1 gene.[13][11]
  • STGD3: A raredominantform of Stargardt disease caused by mutations in theELOVL4gene.
  • Late-onset Stargardt disease is associated withmissensemutations outside known functional domains of ABCA4.[11]

Pathophysiology

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In STGD1, the genetic defect causes malfunction of theATP-binding cassette transporter(ABCA4) protein of thevisual phototransductioncycle. Defective ABCA4 leads to improper shuttling of vitamin A throughout the retina, and accelerated formation of toxic vitamin A dimers (also known as bisretinoids), and associated degradation byproducts. Vitamin A dimers and other byproducts are widely accepted as the cause of STGD1. As such, slowing the formation of vitamin A dimers might lead to a treatment for Stargardt. When vitamin A dimers and byproducts damage the retinal cells, fluorescent granules calledlipofuscinin theretinal pigmented epitheliumof the retina[14]appear, reflecting such damage.

In STGD4, a butterfly pattern ofdystrophyis caused by mutations in a gene that encodes a membrane bound protein that is involved in the elongation ofvery long chain fatty acids(ELOVL4)[15]

Diagnosis

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Diagnosis is firstly clinical through history and examination usually with aSlit-lamp.If characteristic features are found the investigations undertaken will depend on locally available equipment and may includeScanning laser ophthalmoscopywhich highlights areas ofautofluorescencewhich are associated with retinal pathology.Spectral-domain optical coherence tomography,electroretinographyandmicroperimetryare also useful for diagnostic and prognostic purposes.Fluorescein angiographyis used less often than in the past. These investigations may be followed by genetic testing in order to avoid misdiagnosis. Other diseases may have overlapping phenotypic features with Stargardt Disease and the disease itself has multiple variants. In one study, 35% of patients diagnosed with Stargardt Disease through physical ophthalmic examination were found to be misdiagnosed when subsequent genetic testing was done.[16]Genetic testing can be utilized to ensure a proper diagnosis for which the correct treatment can be applied.

Treatment

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At present there is no gene therapy for Stargardt Disease. However, ophthalmologists recommend measures that could slow the rate of progression. There are noprospective clinical trialsto support these recommendations, but they are based on scientific understanding of the mechanisms underlying the disease pathology. There are three strategies doctors recommend for potential harm reduction: reducing retinal exposure to damagingultraviolet light,avoiding excessVitamin Awith the hope of loweringlipofuscinaccumulation and maintaining good general health and diet.[citation needed]

MD Stem Cells' approach using Bone Marrow Derived Stem Cells has shown benefit in various retinal diseases. In Stargardt, 94.1% of patients had improved vision or remained stable with results showing high statistical significance (p=0.0004).[17]Reasons for improvement may include transfer of organelles (mitochondria, lysosomes), enhanced clearing of toxic Vitamin A byproducts, and neuroprotection of photoreceptors.[18]

Ultra-violet light has more energy and is a more damaging wavelength spectra than visible light. In an effort to mitigate this, some ophthalmologists may recommend that the patient wears a broad-brimmed hat or sunglasses when they are outdoors.[19]Sometimes, doctors also instruct their patients to wear yellow-tinted glasses (which filter out blue light) when indoors and in artificial light or in front of a digital screen.

Certain foods, especially carrots, are rich in vitamin A, but the amount from food is not harmful.[19]Foods with a high vitamin A content are often yellow or orange in color, such as squash, pumpkin, and sweet potato, but some, such as liver, are not. There are supplements on the market with more than a daily allowance of vitamin A that should be avoided, but each individual should discuss this with their doctor.

Smoking, overweight or obesity, and poor diet quality may also contribute to more rapid degeneration. On the other hand, the consumption of oily fish, in a diet similar to that which doctors recommend forage related macular degeneration,can be used to slow the progression of the disease.[citation needed]

Advances in technology have brought devices that help Stargardt patients who are losing their vision maintain their independence. Low-vision aids can range from hand lenses to electronic devices and can allow those losing their vision to be able to carry out daily activities.[19]Some patients may even opt for in-person services.

Prognosis

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The long-term prognosis for patients with Stargardt disease is widely variable and depends on the age of onset and geneticalleles.[6][7][8][9]

The majority of patients will progress to legal blindness, which means that central reading vision will be lost. However, perimetry and microperimetry studies indicate that the peripheral light sensitivity is preserved over a long time in a significant fraction of all patients (i.e., >50%).[7][20]Stargardt disease has no impact on general health and life expectancy is normal.[21]Some patients, usually those with the late-onset form, can maintain excellent visual acuities for extended periods and are therefore able to perform tasks such as reading or driving.[15]

Epidemiology

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A 2017 prospective epidemiologic study that recruited 81 patients with STGD over 12 months reported an incidence of between 1 and 1.28 per 10 000 individuals. The median age of presentation was 27 years (range 5–64 years), most (90%) were symptomatic, with a median visual acuity ofSnellenequivalent 20/66.[22]

History

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Karl Stargardt(1875–1927) was a German ophthalmologist born in Berlin. He studied medicine at the University of Kiel, qualifying in 1899. He later became head of the Bonn University's ophthalmology clinic, followed by a post as chair of ophthalmology at the University of Marburg. In 1909 he described 7 patients with a recessively inherited macular dystrophy, now known as Stargardt's disease, being described as a progressive and severe reduction of central vision, which develops in the first and second decade of life. [23][2]

Research

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There are several clinical trials in various stages involving several potential therapeutic areas, gene therapy, stem cell therapy, drug therapy and artificial retinas. In general all are testing the safety and benefits of their respective therapies inphase I or II trials.These studies are designed to evaluate the safety, dose and effectiveness in small number of people in Phase I with Phase II evaluating similar criteria in a larger population but including a greater insight into potential side effects.[citation needed]

Gene therapy is designed to insert a copy of a corrected gene into retinal cells. The hope is to return cell function back to normal and the treatment has the potential to stop disease progression. This therapy will not restore impaired vision back to normal. The research is being undertaken by a partnership betweenSanofiandOxford BioMedica.ALentiviral vectoris used to deliver a normal gene to the target tissue via asubretinalinjection. The therapy is known as SAR422459 and it has been terminated prematurely due to halt in developing the drug product.[24]

Kubota Vision is in Phase III clinical trials of a visual cycle modulator that modulates RPE65 activity to treat Stargardt's. Kubota Vision published the results of a dose range study of a drug known as Emixustat, with findings that will effect dose selection for their phase III trial set to complete in June 2022.[25]

Stem-cell therapyinvolves injecting cells with the potential to mature intodifferentiatedand functioning retinal cells. This therapy has the potential stop disease progression and in the long term improve vision. To improve vision this technique will need to replicate the complex multi-layered andneurallyanatomy of theretina.There are a number of research groups working with stem cells one of which isOcata Therapeutics.[26]

Alkeus Pharma is evaluating the potential of deuterated vitamin A as the drug ALK-001. The hope is that the deuterated vitamin A will reduce the build-up of toxic vitamin A metabolites in the retina and therefore slow rate of visual deterioration. To create deuterated vitamin A some of the hydrogen atoms are replaced with theisotopedeuteriumwhich has an extraneutronand is therefore twice thestandard atomic weightof hydrogen. A Phase II clinical trial is taking place using ALK-001 with an estimated completion date of December 2024.[24][27][28]

MD Stem Cells, a research-physician clinical development company using autologous bone marrow derived stem cells (BMSC), has released results of the Stargardt Disease cohort within their ongoing Stem Cell Ophthalmology Study II (SCOTS2) clinical trial (NCT 03011541).[29]Average visual improvement was 17.96% (95% CI, 16.39 to 19.53%) with 61.8% of eyes improving and 23.5% remaining stable with no adverse events occurring.[30]

Retinal implantsare in the early stages of development and their use could be of benefit to many people withvisual impairmentthough implanting and maintaining an electrical device within the eye that interfaces with theoptic nervepresents many challenges. An example of a device is made byArgus retinal prosthesis,the camera is an external device held on spectacles, the camera signal is processed and then fed via wires into the retina to terminate in someelectrodesthat interface with the optic nerve.[31]

References

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  1. ^Sahel, J.-A.; Marazova, K.; Audo, I. (2015)."Clinical Characteristics and Current Therapies for Inherited Retinal Degenerations".Cold Spring Harbor Perspectives in Medicine.5(2): a017111.doi:10.1101/cshperspect.a017111.PMC4315917.PMID25324231.
  2. ^abK. B. Stargardt (1909)."Über familiäre, progressive Degeneration in der Makulagegend des Auges".Albrecht von Graefes Archiv für Ophthalmologie(in German).71(3): 534–550.doi:10.1007/BF01961301.S2CID12557316.
  3. ^"Stargardt disease: Definition(s) from the Unified Medical Language System ® Diseases Database".diseasesdatabase.Retrieved5 February2018.[permanent dead link‍]
  4. ^ab"Stargardt disease/Fundus flavimaculatus".eyewiki.aao.org.Retrieved5 February2018.
  5. ^Lee, W; Zernant, J; Nagasaki, T; Molday, LL; Su, PY; Fishman, GA; Tsang, SH; Molday, RS; Allikmets, R (26 June 2021)."Cis-acting modifiers in the ABCA4 locus contribute to the penetrance of the major disease-causing variant in Stargardt disease".Human Molecular Genetics.30(14): 1293–1304.doi:10.1093/hmg/ddab122.PMC8255130.PMID33909047.
  6. ^abPfau M, Cukras CA, Huryn LA, Zein WM, Ullah E, Boyle MP; et al. (2022)."Photoreceptor degeneration in ABCA4-associated retinopathy and its genetic correlates".JCI Insight.7(2).doi:10.1172/jci.insight.155373.PMC8855828.PMID35076026.{{cite journal}}:CS1 maint: multiple names: authors list (link)
  7. ^abcCideciyan AV, Swider M, Aleman TS, Tsybovsky Y, Schwartz SB, Windsor EA; et al. (2009)."ABCA4 disease progression and a proposed strategy for gene therapy".Human Molecular Genetics.18(5): 931–41.doi:10.1093/hmg/ddn421.PMC2640207.PMID19074458.{{cite journal}}:CS1 maint: multiple names: authors list (link)
  8. ^abFakin A, Robson AG, Fujinami K, Moore AT, Michaelides M, Pei-Wen Chiang J; et al. (2016)."Phenotype and Progression of Retinal Degeneration Associated With Nullizigosity of ABCA4".Investigative Ophthalmology & Visual Science.57(11): 4668–78.doi:10.1167/iovs.16-19829.PMID27583828.S2CID23322124.{{cite journal}}:CS1 maint: multiple names: authors list (link)
  9. ^abLee, W; Zernant, J; Su, PY; Nagasaki, T; Tsang, SH; Allikmets, R (25 January 2022)."A genotype-phenotype correlation matrix for ABCA4 disease based on long-term prognostic outcomes".JCI Insight.7(2).doi:10.1172/jci.insight.156154.PMC8855796.PMID34874912.
  10. ^Yatsenko et al. 2001
  11. ^abc"Stargardt disease/Fundus flavimaculatus – EyeWiki".
  12. ^"OMIM Entry - * 601691 - ATP-BINDING CASSETTE, SUBFAMILY A, MEMBER 4; ABCA4".
  13. ^"OMIM Entry - * 604365 - PROMININ 1; PROM1".
  14. ^Adler L, 4th; Boyer, NP; Chen, C; Ablonczy, Z; Crouch, RK; Koutalos, Y (2015). "The 11-cis Retinal Origins of Lipofuscin in the Retina".Progress in Molecular Biology and Translational Science.134:e1–12.doi:10.1016/bs.pmbts.2015.07.022.ISBN9780128010594.PMID26310175.{{cite journal}}:CS1 maint: numeric names: authors list (link)
  15. ^abDeutman, August; Hoyng, Carol; van Lith-Verhoeven, Janneke (2006). "Macular dystrophies".Retina(4 ed.). Elsevier Mosby. pp. 1171–74.
  16. ^Ibanez, Manuel Benjamin; Guimarães, Thales Antonio Cabral; Capasso, Jenina; Bello, Nicholas; Levin, Alex V. (March 2021)."Stargardt misdiagnosis: How ocular genetics helps".American Journal of Medical Genetics Part A.185(3): 814–19.doi:10.1002/ajmg.a.62045.ISSN1552-4825.PMID33369172.S2CID229691125.
  17. ^Weiss, Jeffrey N.; Levy, Steven (2021-02-03)."Stem Cell Ophthalmology Treatment Study (SCOTS): Bone Marrow-Derived Stem Cells in the Treatment of Stargardt Disease".Medicines.8(2): 10.doi:10.3390/medicines8020010.ISSN2305-6320.PMC7913552.PMID33546345.
  18. ^"New Stargardt Treatments- MD Stem Cells SCOTS2 or ALK-001 Vitamin A".AP News.2022-11-10.Retrieved2023-09-27.
  19. ^abc"Stargardt Disease | National Eye Institute".nei.nih.gov.Retrieved2021-04-25.
  20. ^Pfau M, Holz FG, Müller PL (2021)."Retinal light sensitivity as outcome measure in recessive Stargardt disease".British Journal of Ophthalmology.105(2): 258–264.doi:10.1136/bjophthalmol-2020-316201.PMID32345606.S2CID216645815.{{cite journal}}:CS1 maint: multiple names: authors list (link)
  21. ^Stargardt Diseasefrom The University of Arizona College of Medicine, Department of Ophthalmology and Vision Science. Retrieved Jan 2012
  22. ^Spiteri Cornish, Kurt; Ho, Jason; Downes, Susan; Scott, Neil W.; Bainbridge, James; Lois, Noemi (2017)."The Epidemiology of Stargardt Disease in the United Kingdom".Ophthalmology Retina.1(6): 508–513.doi:10.1016/j.oret.2017.03.001.hdl:2164/9878.PMID31047443.S2CID55251624.
  23. ^synd/2306atWho Named It?
  24. ^ab"Home – ClinicalTrials.gov".clinicaltrials.gov.Retrieved2021-04-25.
  25. ^Kubota, Ryo; Birch, David G.; Gregory, Jeff K.; Koester, John M. (2020-11-19)."Randomised study evaluating the pharmacodynamics of emixustat hydrochloride in subjects with macular atrophy secondary to Stargardt disease".British Journal of Ophthalmology.106(3): 403–408.doi:10.1136/bjophthalmol-2020-317712.ISSN0007-1161.PMC8867285.PMID33214244.
  26. ^Schwartz, SD; Regillo, CD; Lam, BL; Eliott, D; Rosenfeld, PJ; Gregori, NZ; Hubschman, JP; Davis, JL; Heilwell, G; Spirn, M; Maguire, J; Gay, R; Bateman, J; Ostrick, RM; Morris, D; Vincent, M; Anglade, E; Del Priore, LV; Lanza, R (7 February 2015). "Human embryonic stem cell-derived retinal pigment epithelium in patients with age-related macular degeneration and Stargardt's macular dystrophy: follow-up of two open-label phase 1/2 studies".Lancet.385(9967): 509–16.doi:10.1016/s0140-6736(14)61376-3.PMID25458728.S2CID85799.
  27. ^"A Phase 2 Multicenter, Double-Masked, Randomized, Placebo-Controlled Study to Investigate the Long Term Safety, Tolerability, Pharmacokinetics and Effects of ALK-001 on the Progression of Stargardt Disease".19 July 2021.
  28. ^"Stargardt disease: The leading cause of juvenile macular degeneration".Alkeus Pharma.
  29. ^"Bone Marrow Derived Stem Cell Ophthalmology Treatment Study II".8 September 2021.
  30. ^Weiss, Jeffrey N.; Levy, Steven (2021)."Stem Cell Ophthalmology Treatment Study (SCOTS): Bone Marrow-Derived Stem Cells in the Treatment of Stargardt Disease".Medicines.8(2): 10.doi:10.3390/medicines8020010.PMC7913552.PMID33546345.
  31. ^Chuang, AT; Margo, CE; Greenberg, PB (July 2014). "Retinal implants: a systematic review".The British Journal of Ophthalmology.98(7): 852–56.doi:10.1136/bjophthalmol-2013-303708.PMID24403565.S2CID25193594.
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