Molecular Vision 2003; 9:138-143 <>
Received 18 November 2002 | Accepted 1 April 2003 | Published 24 April 2003

Genetic heterogeneity of butterfly-shaped pigment dystrophy of the fovea

Janneke J. C. van Lith-Verhoeven,1,2 Frans P. M. Cremers,2 Bellinda van den Helm,2 Carel B. Hoyng,1 August F. Deutman1

Departments of 1Ophthalmology and 2Human Genetics, University Medical Center Nijmegen, Nijmegen, The Netherlands

Correspondence to: Dr. Frans P. M. Cremers, Department of Human Genetics, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands; Phone: +31 24 361 3750; FAX: +31 24 354 0488; email:


Purpose: Butterfly-shaped macular dystrophy (BSMD) has so far only been associated with mutations in the peripherin/RDS gene. The initial aim of our study was to investigate the peripherin/RDS gene as the causative gene in a family with BSMD. Subsequently the putative involvement of the ROM-1 gene, 4 genes expressed in cone photoreceptors, all known non-syndromic macular, retinal pigment epithelium and choroidal dystrophy loci, all known Leber congenital amaurosis loci and all known non-syndromic congenital and stationary retinal disease loci was examined.

Methods: Thirteen members from the original family with autosomal dominant BSMD were examined. The protein coding exons of the peripherin/RDS gene were screened for mutations by sequence analysis. Linkage analysis was performed using markers flanking the peripherin/RDS gene to rule out the presence of a heterozygous deletion. Likewise, involvement of the ROM-1 gene, four cone genes, 41 non-syndromic retinal disease loci and one syndromic retinal disease locus was investigated.

Results: Sequence analysis of the peripherin/RDS gene revealed no mutations. In addition, the BSMD phenotype could not be genetically linked to the peripherin/RDS gene, the ROM-1 gene and the four cone genes nor to any of the 42 retinal disease loci.

Conclusions: This study reveals genetic heterogeneity for BSMD by the identification of a BSMD family, which is not associated with a mutation in the peripherin/RDS gene nor with any other known non-syndromic retinal disease gene.


Butterfly-shaped pigment dystrophy of the fovea, also named butterfly-shaped macular dystrophy (BSMD), was described for the first time by Deutman and coworkers [1] and is characterized by bilateral accumulation of pigmented or yellowish material at the level of the retinal pigment epithelium (RPE). Lesions consist of 3 to 5 "wings", resembling the wings of a butterfly. Fundamental for the diagnosis are a subnormal electrooculogram (EOG), normal or only slightly diminished visual acuity, and an autosomal dominant inheritance pattern. Older patients can suffer from markedly reduced visual acuity due to large retinal atrophic lesions in the macular area [2]. Several entities including BSMD, reticular dystrophy [3], macroreticular dystrophy [4], fundus pulverulentus [5], and adult-onset foveomacular vitelliform dystrophy [6] belong to a group of autosomal dominant dystrophies of the RPE, known as pattern dystrophies [7]. Variability of expression of pattern dystrophy has been described within families [8-10] and in a single patient during various stages of the disease [11]. So far BSMD has only been associated with mutations in the peripherin/RDS gene [12-19]. The purpose of this study is to screen the original BSMD family for mutations in the peripherin/RDS gene and to examine putative involvement of the ROM-1 gene, four cone expressed genes, all known non-syndromic autosomal dominant and recessive macular, RPE and choroidal dystrophy loci, all known Leber congenital amaurosis (LCA) loci, and all known non-syndromic congenital and stationary retinal disease loci.


Thirteen individuals from the original Dutch BSMD family were included in this study. An informed consent was obtained from all participating individuals. The medical histories were obtained from two unaffected and eight affected individuals. Subsequent ophthalmic examination included best corrected Snellen visual acuity, slit-lamp biomicroscopy, fundus examination and fluorescein angiography. Five patients (II-1, II-3, II-4, II-8, III-1) underwent electroretinography (ERG) and all eight affected individuals EOG. ERG and EOG were recorded and interpreted as previously described [1,20,21]. In three patients, EOG was performed according to the International Society for Clinical Electrophysiology of Vision protocol. In addition five patients (II-1, II-3, II-4, II-8, III-1) underwent color vision and dark adaptation testing.

For molecular analysis, blood samples of all participating individuals were collected and DNA was isolated as described elsewhere [22]. For mutation analysis of the peripherin/RDS gene, 25 ng of genomic DNA was amplified using the polymerase chain reaction (PCR), under the following conditions: initial denaturation 5 min at 95 °C, denaturation for 30 s at 94 °C, annealing for 30 s at 55 °C, extension for 1 min at 72 °C, and a final extension for 5 min at 72 °C. For peripherin/RDS exon 1, part I (cDNA nucleotides 209-484) [23], we used the forward primer 5'-GTGGGAAGCAACCCGGAC-3', and the reverse primer 5'- AGATCTTCCCAGCCAGCG-3'. For exon 1, part II (cDNA nucleotides 431 - 673)[23], we employed the forward primer 5'-TGATAGGGATGGGGGTGC-3', and the reverse primer 5'CTGTGTCCCGGTAGTACTTC-3'. For exon 1, part III (starting at cDNA nucleotide 611), [23] we used the forward primer 5'-GCTCGCTGGAGAACACCCT-3' and the reverse (intron 1) primer 5'-TCTGACCCCAGGACTGGAAG-3' [23]. For exon 2, we used forward primer (derived from 3' end of the first intron) 5'-AAGCCCATCTCCAGCTGTCT-3' and reverse primer (derived from 5' end of the second intron) 5'-CTTACCCTCTACCCCCAGCTG-3'. For exon 3 we used forward primer (derived from 3' end of the second intron) 5'-AGATTGCCTCTAAATCTCCTC-3' and reverse primer 5'-TGCACTATTTCTCAGTGTTCG-3', located at cDNA nucleotides 1305 to 1325 of the 3' untranslated region [24]. For exon 3, the reverse primer 5'-TGCACTATTTCTCAGTGTTCG-3' located at cDNA nucleotides 1305 to 1325 of the 3' untranslated region was used. Mutation analysis of the peripherin/RDS gene was performed by direct sequencing using a BigDye Terminator chemistry on an ABI Prism 377 (PE Applied Biosystems). Flanking microsatellite markers were chosen from the Généthon database [25] to investigate the peripherin/RDS locus, the ROM-1 locus, 19 autosomal dominant macular, RPE and choroidal dystrophy loci, 9 autosomal recessive macular, RPE and choroidal dystrophy loci and 8 LCA loci (Table 1 and Table 2). Furthermore, 8 autosomal dominant and recessive congenital and stationary retinal disease loci and four chromosomal regions harboring cone photoreceptor expressed genes were examined (Table 3 and Table 4). Finally, one syndromic autosomal recessive retinal degeneration locus at 4q24 (MTP) was tested using microsatellite markers D4S414 and D4S411. Samples were subjected to PCR amplification, with a standard cycling profile of 30 cycles at 94 °C, 55 °C, and 72 °C with 30 s at each step. DNA markers were labeled by the incorporation of α[32P]-dCTP and the products were separated by electrophoresis on a 6.6% denaturing polyacrylamide gel. Haplotype analysis was performed and two-point LOD scores were calculated using the subroutine Mlink of the Linkage package [26-28]. Multipoint analysis was performed using FASTLINK version 2.30 [29,30]. A gene frequency of 0.0001 and a penetrance of 95% were assumed for the disorder.


The clinical features are summarized in Table 5. Visual acuity was normal or nearly normal in all affected individuals except individual II-8, who had a visual acuity of 20/50 in his right eye and 20/200 in his left eye, but he also suffered from a optic neuropathy, due to multiple sclerosis. Ophthalmoscopy revealed pigmented butterfly-shaped structures in both eyes in 6 affected individuals (II-1, II-3, II-4, II-8, III-1, III-4; Figure 1A,C). Individuals III-2 and III-5 had butterfly-shaped pigmentations in one eye, and small pigment alterations without any pattern in the other. The butterfly-shaped pigmentations seemed to be localized in the deeper layers of the retina in or near the RPE. The retinal vessels continued their course across the pigmentations. Individuals II-1, II-4 and II-8, which were 70, 71 and 65 years old respectively at examination, showed parafoveal chorioretinal atrophy, accompanied by peripheral bone spicule-like structures in II-1 and II-4 (Figure 1D). Individual II-8 had developed some peripapillary atrophy. In individual II-3 many peripheral reticular pigmentations were seen (Figure 1E). Five patients had drusen-like alterations surrounding the butterfly-shaped pigmentations. Fluorescein angiograms demonstrated clearly outlined hypofluorescent butterfly-shaped structures in the macular area in all patients (Figure 1B). The EOG was pathological (Arden ration p95: >1.65) in all patients over age 35 years, except for individual III-1, who already had a disturbed EOG from age 14. ERG, color vision and dark adaptation were normal in all 5 patients tested. The normal ERG values of the scotopic and photopic b-wave amplitudes are stated in Table 5 [1].

Direct sequencing of the PCR products of the three exons of the peripherin/RDS gene from cases II-8 and III-1 revealed no mutations. Using haplotype analysis, the peripherin/RDS gene could be excluded (Figure 2). No haplotype could be deduced around the peripherin/RDS gene, that co-inherited with the BSMD phenotype. Notably, individual III-2 had not inherited the D6S426 / D6S1582 haplotype, that was shared by the other affected individuals. The LOD score obtained by multipoint linkage analysis was less than -2 in the entire D6S426 / D6S282 interval. Subsequently, the ROM-1 gene, the 4 cone genes, all 41 non-syndromic retinal disease loci and the syndromic MTP locus at 4q24 could also be excluded by haplotype analysis and multipoint linkage analysis. A LOD score of -2 or less in the entire critical interval of the locus or surrounding the gene was taken as proof that the loci were not linked to the phenotype. Two loci (STGD4 and the GNB2 gene) could not be excluded by multipoint linkage analysis. The locus for STGD4 at chromosome 4p was situated between markers D4S1582 and D4S2397. Using markers D4S2957, D4S431, D4S394, D4S3048, D4S419 and D4S230, multipoint LOD scores varying from -0.25 to -4.1 were obtained. Haplotype analysis revealed three affected individuals that did not show the at risk chromosome 4 haplotype (data not shown). Markers D7S646 and D7S662, flanking the GNB2 gene demonstrated multipoint LOD scores varying from -0.5 to -1.6 between these markers. Haplotype analysis however revealed one affected and one unaffected individual who did not carry the same haplotype of the chromosome 7 interval containing the GNB2 gene (data not shown).


In this family with BSMD, the main clinical features were the butterfly shaped macular lesions, the relatively good visual acuity and the disturbed EOG, while the ERG, color vision and dark adaptation were normal. Only in individual II-8 a diminished visual acuity was found but he also suffered from an optic neuropathy. BSMD shares important similarities with age-related macular degeneration, since in both an abnormal deposition of lipofuscin-like material at the level of the RPE is found, which results in the loss of the overlying photoreceptors.

In several families with pattern dystrophy (among which BSMD), mutations have been found in the peripherin/RDS gene. These include the missense mutations Gly167Asp, Pro210Arg, Pro216Ser, and Cys213Tyr, as well as the protein truncating mutations Gln331stop, a 4-base pair (bp) deletion at codon 140, a 2-bp frameshift deletion at codon 290, a 2-bp frameshift deletion at codons 299/300, and a large deletion that removes exons 2 and 3 of the peripherin/RDS gene [12-19]. The BSMD family described in this study has no mutations in the peripherin/RDS gene. Sequence analysis would not be able to identify a heterozygous deletion of the peripherin/RDS gene. We therefore performed linkage analysis with markers flanking the peripherin/RDS gene, but found no fully cosegregating haplotypes. A Swiss family with pattern dystrophy has been reported in which the genetic defect shows no linkage to the peripherin/RDS gene nor to the rhodopsin gene, but the phenotype of this family has not been described [31].

Because peripherin-2, the protein product of the peripherin/RDS gene forms a heterotetramer with ROM-1, the ROM-1 gene was considered a candidate gene for BSMD. The heterotetrameric peripherin-2/ ROM-1 complex is important for rod photoreceptor disk morphogenesis and mutations in both components result in a defective subunit assembly of the heterotetrameric peripherin-2/ROM-1 complex [32]. Non-allelic heterozygous peripherin/RDS and ROM-1 mutations cause digenic RP [33]. Linkage analysis however excluded the involvement of ROM-1 in this BSMD family.

The VMD2 gene, associated with Best disease, was considered another good candidate gene, because BSMD and Best disease have been found within the same patient and within the same family [8-10]. Moreover Best disease and BSMD share the presence of hyperpigmented material in the RPE, a subnormal EOG, a normal ERG and an autosomal dominant pattern of inheritance [34,35]. The VMD2 gene is located on chromosome 11q13 [36,37]. Nevertheless, this family showed no linkage to markers flanking the VMD2 gene.

Subsequent linkage analysis excluded all other macular, RPE, and choroidal dystrophy loci, the LCA loci, the congenital and stationary retinal disease loci, and 4 genes expressed in cones including the β-subunit of guanine nucleotide binding protein (GNB2), the β-subunit of guanine nucleotide binding protein (GNGT2) and the α and β subunits of cone cGMP phosphodiesterase 6H (PDE6C and PDE6H) [38-42].

In this study we present clear evidence of genetic heterogeneity for BSMD. We could exclude not only the peripherin/RDS gene, but all other known macular, RPE and choroidal dystrophy loci, all known LCA loci and all known congenital and stationary retinal disease loci. In the future we will expand the BSMD family which will enable us to perform a whole genome linkage scan.


We thank Dr. H. Kremer for her advice on linkage statistics. We are grateful to the family members for their cooperation. These studies were supported by grants of the Stichting Researchfonds Oogheelkunde, the Stichting Ondersteuning Oogheelkunde 's-Gravenhage and the Stichting Blindenhulp.


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