blepharophimosis

3MC Syndromes

Clinical Characteristics
Ocular Features: 

The major ocular features involve the periocular structures.  These result in the typical facial dysmorphism and include hypertelorism, blepharoptosis, blepharophimosis, and highly arched eyebrows. Ptosis, unilateral or bilateral, can be present.

One patient was reported to have unilateral aniridia and a corneal leucoma.  Tear duct atresia was reported in another individual.

Systemic Features: 

Systemic features are highly variable in their presence and severity.   Facial clefting, growth deficiency, cognitive impairment, and hearing loss are present about half the time in some combination while craniosynostosis, urogenital anomalies, and radioulnar synostosis are seen in about a third of individuals.  More rare features include cardiac defects and abdominal midline defects (omphalocele and diastasis recti).

Genetics

This condition (3MC) is now postulated to include at least 3 disorders (Malpuech-Michels-Mingarelli-Carnevale syndromes) and considered here as a single autosomal recessive disease complex with overlapping clinical features that requires genotyping for diagnostic separation.  These are: 3MC1 syndrome (257920) resulting from homozygous mutations in the MASP1 gene (3q27.3), 3MC2 syndrome (265050) caused by mutations in the COLEC11 gene (2p25.3) and 3MC3 (248340) with mutations in the COLEC10 gene (8q24.12).

Pedigree: 
Autosomal recessive
Treatment
Treatment Options: 

No effective general treatment has been reported.

References
Article Title: 

COLEC10 is mutated in 3MC patients and regulates early craniofacial development

Munye MM, Diaz-Font A, Ocaka L, Henriksen ML, Lees M, Brady A, Jenkins D, Morton J, Hansen SW, Bacchelli C, Beales PL, Hernandez-Hernandez V. COLEC10 is mutated in 3MC patients and regulates early craniofacial development. PLoS Genet. 2017 Mar 16;13(3):e1006679. doi: 10.1371/journal.pgen.1006679. eCollection 2017 Mar.

PubMed ID: 
28301481

Mutations in lectin complement pathway genes COLEC11 and MASP1 cause 3MC syndrome

Rooryck C, Diaz-Font A, Osborn DP, Chabchoub E, Hernandez-Hernandez V, Shamseldin H, Kenny J, Waters A, Jenkins D, Kaissi AA, Leal GF, Dallapiccola B, Carnevale F, Bitner-Glindzicz M, Lees M, Hennekam R, Stanier P, Burns AJ, Peeters H, Alkuraya FS, Beales PL. Mutations in lectin complement pathway genes COLEC11 and MASP1 cause 3MC syndrome. Nat Genet. 2011 Mar;43(3):197-203.

PubMed ID: 
21258343

Intellectual Disability with Dysmorphic Facies and Ptosis

Clinical Characteristics
Ocular Features: 

The eyes appear widely spaced and the lid fissures slant downward.  Ptosis and blepharophimosis are present.  Strabismus is an uncommon feature.

Systemic Features: 

The characteristic facial profile (round, flat) is evident at birth. Microcephaly has been seen in some children.  Low birthweight is common.  Most infants feed poorly with general growth delay and short stature becoming evident in childhood.  Hypotonia and joint hypermobility are constant features.  Gross and fine motor movements appear uncoordinated.  Expressive language is delayed and impaired.  Intellectual disability is mild and achievement of developmental milestones may be delayed.  Seizures are seen in about half of affected individuals.  Brain MRIs may reveal mild white matter anomalies.  Spinal fusion among cervical vertebrae is common.

Individuals may live to adulthood.

Genetics

Heterozygous mutations in the BRPF1 gene (3p25) are responsible for this condition.

Pedigree: 
Autosomal dominant
Treatment
Treatment Options: 

No effective treatment has been reported.

References
Article Title: 

Mutations in Histone Acetylase Modifier BRPF1 Cause an Autosomal-Dominant Form of Intellectual Disability with Associated Ptosis

Mattioli F, Schaefer E, Magee A, Mark P, Mancini GM, Dieterich K, Von Allmen G, Alders M, Coutton C, van Slegtenhorst M, Vieville G, Engelen M, Cobben JM, Juusola J, Pujol A, Mandel JL, Piton A. Mutations in Histone Acetylase Modifier BRPF1 Cause an Autosomal-Dominant Form of Intellectual Disability with Associated Ptosis. Am J Hum Genet. 2017 Jan 5;100(1):105-116.

PubMed ID: 
27939639

Mutations in the Chromatin Regulator Gene BRPF1 Cause Syndromic Intellectual Disability and Deficient Histone Acetylation

Yan K, Rousseau J, Littlejohn RO, Kiss C, Lehman A, Rosenfeld JA, Stumpel CT, Stegmann AP, Robak L, Scaglia F, Nguyen TT, Fu H, Ajeawung NF, Camurri MV, Li L, Gardham A, Panis B, Almannai M, Sacoto MJ, Baskin B, Ruivenkamp C, Xia F, Bi W; DDD Study.; CAUSES Study., Cho MT, Potjer TP, Santen GW, Parker MJ, Canham N, McKinnon M, Potocki L, MacKenzie JJ, Roeder ER, Campeau PM, Yang XJ. Mutations in the Chromatin Regulator Gene BRPF1 Cause Syndromic Intellectual Disability and Deficient Histone Acetylation. Am J Hum Genet. 2017 Jan 5;100(1):91-104.

PubMed ID: 
27939640

Kaufman Oculocerebrofacial Syndrome

Clinical Characteristics
Ocular Features: 

Alterations in the morphology of periocular structures is the most consistent ocular feature.  These include epicanthal folds, upward-slanting lid fissures, ptosis, blepharophimosis, sparse eyebrows, and telecanthus.  However, pale optic discs, iris colobomas, microcornea, strabismus, nystagmus, and hypertelorism are variably present. 

Systemic Features: 

There is both intrauterine and postnatal growth retardation.  Hypotonia is often noted along with general psychomotor delays.  Neonatal respiratory distress and laryngeal stridor may be present.  The intellectual disability can be severe.  Corpus callosum aplasia and hypoplasia have been reported.  Microcephaly and brachycephaly with delayed suture closure are features.  The face is long and narrow and the mouth is disproportionally large.  A high arched palate can be present and the pinnae are often deformed, posteriorly rotated and may be accompanied by preauricular skin tags. The teeth appear widely spaced (diastema) and the lower jaw is underdeveloped.

Genetics

Kaufman BPIDS syndrome results from homozygous or compound heterozygous mutations in the UBE3B gene (12q23).

Pedigree: 
Autosomal dominant
Treatment
Treatment Options: 

No general treatment is available although repair of some specific malformations is possible.

References
Article Title: 

Deficiency for the ubiquitin ligase UBE3B in a blepharophimosis-ptosis-intellectual-disability syndrome

Basel-Vanagaite L, Dallapiccola B, Ramirez-Solis R, Segref A, Thiele H, Edwards A, Arends MJ, Miro X, White JK, Desir J, Abramowicz M, Dentici ML, Lepri F, Hofmann K, Har-Zahav A, Ryder E, Karp NA, Estabel J, Gerdin AK, Podrini C, Ingham NJ, Altmuller J, Nurnberg G, Frommolt P, Abdelhak S, Pasmanik-Chor M, Konen O, Kelley RI, Shohat M, Nurnberg P, Flint J, Steel KP, Hoppe T, Kubisch C, Adams DJ, Borck G. Deficiency for the ubiquitin ligase UBE3B in a blepharophimosis-ptosis-intellectual-disability syndrome. Am J Hum Genet. 2012 Dec 7;91(6):998-1010.

PubMed ID: 
23200864

An oculocerebrofacial syndrome

Kaufman RL, Rimoin DL, Prensky AL, Sly WS. An oculocerebrofacial syndrome. Birth Defects Orig Artic Ser. 1971 Feb;7(1):135-8.

PubMed ID: 
5006210

Cranial Dysinnervation Disorders with Strabismus and Arthrogryposis

Clinical Characteristics
Ocular Features: 

Strabismus and/or ophthalmoplegia are important features of a group of conditions known as cranial dysinnervation disorders.  Ptosis, Duane syndrome, V pattern exotropia and various degrees of ophthalmoplegia may be seen.  There may be considerable asymmetry in the manifestations in the two eyes.  Epicanthal folds, blepharophimosis, and hypermetropia are sometimes present.  Some patients have corneal leukomas, keratoglobus, high corneal astigmatism, and dysplastic optic disks. 

A pigmentary retinopathy and folds in the macula with an abnormal ERG has been reported.  Subnormal vision has been reported in some patients.

Systemic Features: 

Patients are often short in stature with pectus excavatum, spine stiffness, highly arched palate, and club feet.  Limited forearm rotation and wrist extension may be present.  The fingers appear long and often have contractures while the palmar and phalangeal creases may be absent.  Camptodactyly and clinodactyly are common.  Deep tendon reflexes are often hyporeactive and decreased muscle mass has been noted.  The muscles seem "firm" to palpation.  Restrictive lung disease has been reported.  Hearing loss is experienced by some individuals.

Genetics

Distal arthrogryposis type 5D is caused by homozygous or compound heterozygous mutations in the ECEL1 gene located at 2q36.  However, a similar phenotype (albeit with more severe ocular manifestations) results from heterozygous mutations in PIEZO2 (18p11).  Heterozygous mutations in the PIEZO2 gene have also been reported to cause distal arthrogryposis type 3 (Gordon syndrome [114300]) and Marden-Walker syndrome (248700) and all of these may be simply phenotypical variations of the same disorder.

Pedigree: 
Autosomal dominant
Autosomal recessive
Treatment
Treatment Options: 

There is no treatment for this condition.  Patients with subnormal vision may benefit from low vision aids and selective surgery may be helpful in reducing the physical restrictions from physical deformities.

References
Article Title: 

Mutations in PIEZO2 cause Gordon syndrome, Marden-Walker syndrome, and distal arthrogryposis type 5

McMillin MJ, Beck AE, Chong JX, Shively KM, Buckingham KJ, Gildersleeve HI, Aracena MI, Aylsworth AS, Bitoun P, Carey JC, Clericuzio CL, Crow YJ, Curry CJ, Devriendt K, Everman DB, Fryer A, Gibson K, Giovannucci Uzielli ML, Graham JM Jr, Hall JG, Hecht JT, Heidenreich RA, Hurst JA, Irani S, Krapels IP, Leroy JG, Mowat D, Plant GT, Robertson SP, Schorry EK, Scott RH, Seaver LH, Sherr E, Splitt M, Stewart H, Stumpel C, Temel SG, Weaver DD, Whiteford M, Williams MS, Tabor HK, Smith JD, Shendure J, Nickerson DA; University of Washington Center for Mendelian Genomics, Bamshad MJ. Mutations in PIEZO2 cause Gordon syndrome, Marden-Walker syndrome, and distal arthrogryposis type 5. Am J Hum Genet. 2014 May 1;94(5):734-44.

PubMed ID: 
24726473

Waardenburg Syndrome, Type 3

Clinical Characteristics
Ocular Features: 

Type 3 Waardenburg syndrome has many of the features of other types but with the addition of upper limb anomalies.  Dystopia canthorum and a broad nasal root are characteristic.  Iris heterochromia is present in some patients.  Hypopigmentation may be seen in lashes and eyebrows.

Systemic Features: 

The upper limbs may appear underdeveloped with flexion contractures, fusion of the carpal bones and sometimes syndactyly.  A white forelock may or may not be present.  The cranial bones may be anomalous and rare patients can have microcephaly with significant mental retardation.  Mental function is usually normal though. Occasional patients have cleft palate and/or lip. Hearing loss is of the sensorineural type.  Hypopigmented skin patches are sometimes present but not all patients have them.

Genetics

The uniqueness of Waardenburg syndrome types 1 and 3 remains to be established.  Mutations in the PAX3 gene are responsible for both types and both have been found in the same family.  The phenotype is transmitted in an autosomal dominant pattern in either case but several families have been reported with type 1 WS in parents heterozygous for PAX3 mutations who had a homozygous child with the type 3 phenotype.  However, heterozygous individuals with type 3 have also been reported and the relationship of the two types remains unknown.

Craniofacial-deafness-hand syndrome(122880) with mutations in PAX3 has many features similar to those found in Waardenburg syndrome type 3 and may or may not be a unique disorder.

Pedigree: 
Autosomal dominant
Autosomal recessive
Treatment
Treatment Options: 

There is no treatment for the syndrome but cochlear implants might be helpful.

References
Article Title: 

Saethre-Chotzen Syndrome

Clinical Characteristics
Ocular Features: 

The lids are often ptotic and asymmetrically so in keeping with the skull asymmetry.  Strabismus is common.  Optic atrophy, downward slanting lid fissures, epicanthal folds, and dacryostenosis have also been reported.

Systemic Features: 

The skull is acrocephalic and asymmetrical.  The frontal hairline is low.  The external ear and especially the crus of the ear are malformed and the latter is sometimes considered a valuable diagnostic sign.  There is frequently mild soft tissue syndactyly of the third, fourth and fifth toes, and the distal phalanges of the hallux may be bifid.  Syndactyly of the fingers is sometimes present as well.  Clefting of the soft and hard palates is commonly present and a few patients have had joint contractures.  Hearing loss of all types has been reported.  Mental development seems to be normal.  An increased risk of breast cancer has been found among Swedish patients.

SCS is considered to be one of the more common types of syndromic craniosynostosis.

Genetics

Saethre-Chotzen syndrome is caused by mutations in the TWIST1 (10q26) and possibly FGFR2 genes suggesting genetic heterogeneity.  There is also a great deal of clinical heterogeneity.  This syndrome is sometimes confused with Gorlin-Chaudhry-Moss syndrome (233500).  Pedigrees are consistent with autosomal dominant inheritance.

Pedigree: 
Autosomal dominant
Treatment
Treatment Options: 

There is no known treatment except for cranioplasty and repair of palate clefting.

References
Article Title: 

BPES Syndrome

Clinical Characteristics
Ocular Features: 

This is primarily a dysplasia of the eyelids and adnexae.  The acronym is derived from the longer title sometimes used: blepharophimosis, ptosis, and epicanthus inversus syndrome.  The palpebral fissures are small and the curve of the epicanthal fold is mediolateral, but below the medial canthus.  The nasal bridge is flat or at least low, and the lids are ptotic.  Telecanthus may be present as well.  Refractive errors, strabismus, nystagmus, and amblyopia are often associated.  Entropion with trichiasis may require surgical attention.  Mutations in the FOX family of genes are associated with a wide variety of ocular anomalies including microcornea, trabecular dysgenesis, optic nerve hypoplasias and colobomas that are sporadically present in BPES syndrome.

Alacrima is a feature in many cases, caused by hypoplasia or aplasia of the major lacrimal gland.

Systemic Features: 

This condition is sometimes associated with ovarian failure although breast development is often normal.  The resultant infertility is an example of a sex-limited autosomal trait.  The syndrome can result from cytogenetic aberrations as well but individuals with these usually have other malformations such as contractures, mental defects, microcephaly, growth retardation, etc.

Some authors have considered individuals with the typical features of BPES who also have genitourinary malformations and cognitive deficits as examples of BPES plus syndrome.  A recent report, for example, describes two sibs, a male and a female, with some features of this syndrome plus posteriorly rotated ears, hypertelorism, telecanthus, micrognathia and severe psychomotor retardation.  The responsible mutation was not identified and its relationship to BPES remains unknown.  Another individual with typical ocular and systemic features of BPES in addition to cryptorchidism, developmental delay, and syndactyly, was found to have a mutation in the gene KAT6B in the absence of mutations in FOXL2. 

The phenotypic spectrum of this condition is extensive and it is likely that multiple mutations are collectively responsible for the clinical heterogeneity.

Genetics

This is an autosomal dominant condition with sex-limited characteristics in females (infertility, small uterus, atrophic ovaries).  The karyotype in females is normal.  It is one of the rare conditions with an apparent maternal age effect, at least in sporadic cases which are not uncommon. 

Mutations in the FOXL2 gene at 3q23 seem to be responsible for at least some familial cases. It codes for a gene active in the mesenchyme of the eyelids and in the ovarian follicle, at least in mice.  About 12% of patients do not have a FOXL2 mutation though. Numerous mutations have been found, some of which cause premature ovarian failure (sometimes labeled BPES type I) while others cause only lid maldevelopment (BPES type II).

A mutation in KAT6B (10q22.2) has been found in a single individual with features typical of BPES in whom no FOXL2 mutations were present.  It has been suggested that BPES patients without mutations in FOXL2 should be sequenced for mutations in KAT6B. 

Pedigree: 
Autosomal dominant
Treatment
Treatment Options: 

Lid surgery might be helpful in some patients with severe ptosis and/or trichiasis.

References
Article Title: 
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