The Wnt pathway plays important yet diverse roles in health and disease. Mutations in the Wnt receptor FZD4 gene have been confirmed to cause familial exudative vitreoretinopathy (FEVR). FEVR is characterized by incomplete vascularization of the peripheral retina, which can lead to vitreous bleeding, tractional retinal detachment, and blindness. We screened for mutations in the FZD4 gene in five families with FEVR and identified five mutations (C45Y, Y58C, W226X, C204R, and W496X), including three novel mutations (C45Y, Y58C, and W226X). In the retina, Norrin serves as a ligand and binds to FZD4 to activate the Wnt signaling pathway in normal angiogenesis and vascularization. The cysteine-rich domain (CRD) of FZD4 has been shown to play a critical role in Norrin-FZD4 binding. We investigated the effect of mutations in the FZD4 CRD in Norrin binding and signaling in vitro and in vivo. Wild-type and mutant FZD4 proteins were assayed for Norrin binding and Norrin-dependent activation of the canonical Wnt pathway by cell-surface and overlay binding assays and luciferase reporter assays. In HEK293 transfection studies, C45Y, Y58C, and C204R mutants did not bind to Norrin and failed to transduce FZD4-mediated Wnt/-catenin signaling. In vivo studies using Xenopus embryos showed that these FZD4 mutations disrupt Norrin/-catenin signaling as evidenced by decreased Siamois and Xnr3 expression. This study identified a new class of FZD4 gene mutations in human disease and demonstrates a critical role of the CRD in Norrin binding and activation of the -catenin pathway.Pathological growth of new blood vessels in the retinal vasculature (neovascularization) has been implicated in several human diseases, including familial exudative vitreoretinopathy (FEVR), 3 retinopathy of prematurity, age-related macular degeneration, and diabetic retinopathy. Complications of neovascularization include bleeding, retinal detachment, and irreversible scarring of the retina. FEVR is a developmental disorder characterized by incomplete vascularization of the peripheral retina (1-3). Mutations in FZD4 (Frizzled 4) have been linked to autosomal dominant forms of FEVR (4). The primary effect of FZD4 mutations is caused by the premature arrest of retinal angiogenesis within the peripheral retina (5). Complications arising from incomplete retinal vascularization and subsequent retinal ischemia include development of hyperpermeable vessels, neovascularization, bleeding, and tractional retinal detachment. In severely affected patients with FZD4 mutations, blindness may occur before 10 years of age, whereas mildly affected individuals may not be aware of symptoms and are diagnosed only by fluorescein angiography.Activation of the canonical Wnt pathway in the retina has been shown to be developmental stage-dependent and spatially modulated and is also important in retinal regeneration (6, 7). FZD4 is a member of the Frizzled family of seven-transmembrane Wnt-binding receptors. The N-terminal extracellular cysteine-rich domain (CRD), conserved among F...