Retinoschisin is a 24-kDa discoidin domain-containing protein that is secreted from photoreceptor and bipolar cells as a large disulfide-linked multisubunit complex. It functions as a cell adhesion protein to maintain the cellular organization and synaptic structure of the retina. Over 125 different mutations in the RS1 gene are associated with X-linked juvenile retinoschisis, the most common form of early onset macular degeneration in males. To identify molecular determinants important for retinoschisin structure and function and elucidate molecular and cellular mechanisms responsible for X-linked juvenile retinoschisis, we have analyzed the expression, protein folding, disulfide-linked subunit assembly, intracellular localization, and secretion of wild-type retinoschisin, 15 Cys-to-Ser variants and 12 disease-linked mutants. Our studies, together with molecular modeling of the discoidin domain, identify Cys residues involved in intramolecular and intermolecular disulfide bonds essential for protein folding and subunit assembly. We show that misfolding of the discoidin domain, defective disulfide-linked subunit assembly, and inability of retinoschisin to insert into the endoplasmic reticulum membrane as part of the protein secretion process are three primary mechanisms responsible for the loss in the function of retinoschisin as a cell adhesion protein and the pathogenesis of X-linked juvenile retinoschisis.X-linked juvenile retinoschisis (XLRS) 1 is the most common form of early onset macular degeneration in males (1, 2). It is characterized by a mild to severe decrease in visual acuity, radial streaks extending from the central retina due to a splitting of the inner retina, progressive macular atrophy, and reduction in the electroretinogram b-wave (2-5). Lesions in the peripheral retina associated with impairment in peripheral vision are observed in half the cases. During the course of the disease, complications can arise, which include retinal detachment, vitreal hemorrhaging, and neovascular glaucoma leading to a poor outcome.The RS1 gene responsible for XLRS was identified by positional cloning and found to encode a 24-kDa protein called retinoschisin, or RS1 (6), that is secreted from photoreceptor and bipolar cells as a disulfide-linked oligomeric complex (7,8).The polypeptide consists of a leader sequence with a putative signal peptidase cleavage site and a discoidin domain spanning most of the protein (6). Discoidin domains, first identified in the discoidin I protein of Dictyostelium discoidium (9, 10), have now been found in many secreted and transmembrane proteins, including blood coagulation factors, tyrosine kinase receptors, and proteins involved in neural development (11-13). The function of the discoidin domain is not well understood, but in some proteins it has been implicated in cell adhesion and cell signaling through protein-protein, protein-carbohydrate, or protein-lipid interactions. Recently, the three-dimensional crystal structures of the C2 discoidin domain of blood coagulation Factors...