(Br J Ophthalmol 1999;83:914-918) Stargardt's disease (STGD) presents in the first or second decade of life with a bilateral gradual diminution of vision due to progressive atrophy of the macular retinal pigment epithelium and the choriocapillaris in combination with degeneration of the photoreceptors of the posterior pole.1 STGD is caused by mutations in the retina specific ATP binding cassette transporter (ABCR) gene, which also has been shown to be involved in age related macular degeneration (AMD), although the latter finding has been disputed. [2][3][4] We decribe a single consanguineous family with two diVerent phenotypes: cone-rod-like dystrophy (CRD-like) and a retinitis pigmentosa-like dystrophy (RPlike). These phenotypes co-segregated with DNA markers flanking the ABCR gene and subsequent sequence analysis revealed compound heterozygosity (CRD-like) and homozygosity (RP-like) for ABCR mutations.
Patients and methods
PATIENTSPatients of a consanguineous family with hereditary retinal degeneration originally described by Deutman 5 as centroperipheral tapetoretinal degeneration resembling STGD were reevaluated. All members of the family were examined by one of the authors (CBH). Two diVerent phenotypes could be distinguished based on the clinical findings only. After consulting with the department of human genetics we collected blood samples for molecular genetic analysis, after informed consent was obtained. Patient IV-3 had to be examined at home because of her poor general condition. Unfortunately she died 3 months later.
CLINICAL AND ELECTROPHYSIOLOGICAL
INVESTIGATIONSAfter the ophthalmic history was taken, all patients underwent a standard ophthalmological evaluation including detailed fundus examination. In addition, fundus photography, fluorescein angiography, and electroretinography (ERG) were performed. In ERG tests, the patients faced a modified sphere of a Goldmann-Weekers adaptometer, lit by two 40 W incandescent lamps in order to furnish a Ganzfeld adaptation. After a scleral contact lens, equipped with measuring electrodes, was inserted, a reference electrode was placed on the forehead and the patient was earthed by means of two earclip electrodes. A xenon flashlight was used for flash responses (flash luminance 6.85 cd/m 2 /s photopic and 0.85 cd/m 2 /s scotopic). Measurements were taken at photopic and adaptation levels. The scotopic ERG was a rod isolated dark adapted scotopic response with white (12 minutes of dark adaptation) and blue stimuli (15 minutes of dark adaption). This ERG technique 6 does not precisely meet the ISCEV standard, but for reasons of comparison over a long period of time (patient V-9, follow up 1969-95) the same method was applied. The lower limit of normality with this technique was 100 µV for the photopic b-wave, 150 µV for the scotopic b-wave with a white stimulus, and 170 µV when a blue stimulus was used. Br J Ophthalmol 1999;83:914-918 914