CONGENITAL GLAUCOMA

The genetics of primary congenital glaucoma

Richard A. Armstrong D.Phil

P
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40

rimary congenital glaucoma

(PCG) is a rare disorder
accounting for between 0.01%
and 0.04% of cases of total blindness.1
Although present at birth, the
condition may not be recognised until
infancy or even early childhood. The
impact on the visual development of
the child can be considerable and
early recognition followed by
appropriate therapy can significantly
improve future quality of life.
In the majority of cases, PCG is
bilateral and results from interference
with the outflow of aqueous humor
from the eye due to a congenital defect
in the development of the anterior
chamber. Male infants may be at
greater risk compared with females.
PCG may occur as an isolated
anomaly or be associated with a
number of more complex syndromes
such as neurofibromatosis. Although
the majority of cases occur more or
less sporadically in the population,
there is increasing evidence that
genetics may play a role in the
development of the disorder. A
number of cases are now recognised
as familial, and within affected
families the disorder exhibits either
an autosomal recessive pattern of
inheritance or a polygenic inheritance
pattern, ie involving several genes and
the environment.
A previous article in the genetic
series2 described the patterns of
inheritance associated with juvenile
and adult-onset glaucoma, the genes
that have been linked to these
conditions, and considered how the
effects of specific gene defects could
lead to the development of glaucoma.
This article concentrates exclusively
on PCG and considers: 1) the clinical
and pathological features of the
disorder, 2) the development of the
anterior chamber, 3) the differential
diagnosis of PCG, 4) the genetic
factors that may be associated with
PCG, and 5) how the presence of
abnormal genes might cause PCG.

General features of PCG

Typical clinical manifestations of PCG
include
photophobia,
epiphora
(increased
tear
production),

Figure 1: Section through a human eye showing the typical features of buphthalmos. Note
in particular the enlarged cornea, the deep anterior chamber, atrophy of the iris, the thin
sclera, and cupping of the optic disc.
blepharospasm, and a hazy enlarged
cornea.
Of
these
symptoms,
photophobia is probably the most
consistently present and this
symptom
may
persist
into
adolescence. However, the presence
of any of these signs in an infant
should arouse suspicion of PCG. A
cloudy cornea begins as a slight hazy
opacity but later the cornea becomes
more opaque with the development of
stromal swelling. Increase in the size
of the cornea is usually the result of a
greater tension on the relatively
elastic cornea and sclera of the infant
eyeball and therefore the condition is
usually accompanied by a general
enlargement of the eye. The diameter
of the infant cornea is normally
10-11mm increasing to 12mm at one
year of age. As a consequence, a
diameter of greater than 12mm should
be considered as an indication of
possible PCG in infants.
Increase in the size of the cornea is
also associated with an elevation of
intraocular pressure (IOP). Breaks
occur in Descemets membrane
beginning at the periphery of the
cornea parallel with the limbus. Later

these breaks may begin to affect the

central regions of the cornea. The
optic disc may remain normal,
despite the high IOP, due to the
yielding characteristics of the sclera
and the general enlargement of the
eyeball. Nevertheless, by the time
glaucoma is diagnosed in the child,
the optic nerve head is likely to be
abnormal. If the condition is
untreated or if the pressure is not
adequately controlled, then typical
optic disc changes such as disc pallor
and cupping may appear. Hence,
measurement of the IOP is essential in
infants where PCG is suspected.
Tonometry can often be accomplished
in a young childs eye with a
handheld instrument such as a
Perkins tonometer.

Buphthalmos
The term buphthalmos refers to the
typical appearance of the eye in PCG
(Figure 1). Without treatment, the
disease progresses slowly and the eye
enlarges. In particular, the cornea
becomes abnormally enlarged, thin,
and bulging and is accompanied by

CONGENITAL GLAUCOMA

Associated disorders and syndromes

PCG may occur as an isolated
condition or as part of a more complex
syndrome. For example, in the case of
a 4-year-old male infant with trisomy
13 (three copies of chromosome 13 are
present), there was severe slowing
down of thought processes and a
reduction in physical movement
(psychomotor retardation), abnormally
low
muscle
tone
(muscular
hypotonia), cerebral convulsions,
bilateral PCG leading to buphthalmos,
and bilateral optic nerve atrophy.3
Moreover, in another study, an
identical twin presented at birth with
unilateral PCG accompanied by
neurofibromatosis with spinal cord
involvement.4 Hence, newborns with
unilateral PCG should raise a
suspicion
of
possible
neurofibromatosis. Bupthalmos can
also occur together with unilateral
persistent
hyperplastic
primary
vitreous cataract, a condition which
arises from the persistence of the
hyaloid vessel which joins the optic
nerve to the back of the lens.
In addition, there are a number of
congenital anomalies in which
glaucoma occurs with relatively high
frequency but which develop during
the teenage years or in the early
twenties.
These
include
such
conditions as aniridia (complete or
partial loss of the iris), hemangioma of
the face (Sturge-Weber syndrome),
defective
development
of
the
mesoderm (mesodermal dysgenesis),
neurofibromatosis,
Marfans
syndrome,
and
Marchesanis
syndrome. Hence, in a 28-year-old
male with trisomy affecting part of
chromosome 7, and partial monosomy
affecting chromosome 15 resulting
from
a
paternal
chromosomal
rearrangement
(translocation),
there was bilateral PCG accompanying
the typical manifestations of the
partial trisomy.5

Differential diagnosis
The diagnosis of PCG requires the
presence of buphthalmos in at least
one eye together with an increase in
IOP before three years of age.6 If a larger
than normal eye is present, however,
then there may be several possible
causes.7 First, the presence of an
intraocular
mass
such
as
retinoblastoma should be excluded.
Second,
the
presence
of
neurofibromatosis can also result in an
enlarged eye.4 Third, a diffuse
enlargement of the eye may be
associated with a connective tissue
disorder or related to axial myopia.
Fourth, if enlargement of the eye is
more focal it may be attributable to
staphyloma, viz., a thinned area of
sclera lined by the choroid and which
has a tendency to bulge under the
influence of increased IOP. This
condition may occur when the sclera is
thinned as a consequence of high
myopia or as a result of injury. Fifth, if
one small eye is present, the normal
sized eye may be incorrectly judged as
large. Sixth, bilateral enlargement of
the cornea in an otherwise healthy eye
may occur in congenital megalocornea,
a non-progressive enlargement of the
cornea to 13mm or greater. However, in
this condition there is no photophobia
or corneal swelling, no break in
Descemets membrane, no abnormality

detectable in the anterior chamber

angle, no cupping of the optic disc, and
no significant increase in IOP.

Development of the anterior chamber

PCG is believed to result from a
congenital defect in the development of
the angle of the anterior chamber
(Figure 2). As early as week 12 during
development, a wedged shaped mass of
mesenchyme can be identified at the
anterior chamber angle, ie, at the
junction of the papillary membrane
and the lateral margins of the cornea.
Within this wedged shaped portion of
tissue there is a row of small
capillaries, which are lined with
mesoderm-derived
vascular
endothelial cells. By the fifth month,
early trabeculae are apparent separated
by intervening spaces and the
capillaries are fused to form a single
vessel (the canal of Schlemm), which
is continuous with the collector
channels
and
scleral
vessels.
Subsequently, the meshwork becomes
specialised into inner uveal trabeculae,
numerous intermediate layers of
lamellar corneoscleral trabeculae, and
a more loosely organised cribriform
meshwork. Perforations of the cuboidal
epithelial cells, which line the inner
surface of the meshwork and which
allow communication between the

Anterior surface
of cilary body
Limbus junction
between the
cornea and sclera

Canal of schlemm
Posterior
chamber
Trabeculae

Iris
Anterior
chamber

Figure 2: The anterior angle showing the Canal of Schlemm and the trabeculae. Diagram
courtesy of Dr Mark Dunne, Aston University.

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increasing opacity. The anterior

chamber becomes deeper, the pupil
dilated, and the iris begins to
degenerate. The sclera is thin often
with a bluish tinge, the consequence of
the uveal pigment showing through.
Later the optic disc develops pallor,
cupping, and becomes atrophic. These
changes may not develop continuously
in all patients but become arrested at
some stage. Nevertheless, without
treatment the changes can progress to
complete blindness.

CONGENITAL GLAUCOMA

Disorder

Locus

Gene

Location

Gene abnormalities

Pure PCG

GLC3A

P4501B1
(CYP1B1)

2p21

136bp deletion exon III,

Insertion exon II
Deletion 5 end of III
C/T transition at codon
355
Substitution at codon 368

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42

Syndromes
with PCG

GLC3B

Unknown

1p36

Unknown

GLC3C

Unknown

14q24.3

Unknown

GLC1A

Myocilin

1q21-q23

Homozygous mutations
in intron 2

13

Trisomy

Trisomy

15

Trisomy

Table 1: Genes associated with Primary Congenital Glaucoma (PCG). Abbreviations: p = p arm of chromosome, q = q arm of chromosome,
bp = base pairs, 5 = 5 prime end of DNA strand, C = Cytosine, T = Thymine
anterior chamber and the meshwork,
occur from 15 weeks onward. The
anterior chamber itself develops
between the sixth and ninth month of
foetal life as a chink in the mesoderm
between the iris root and the developing
trabeculum. If the mesoderm does not
entirely regress in this region, an
impervious layer may remain bridging
the angle between the iris and the
cornea and which impedes access of
aqueous to the trabecular meshwork.

The genetics of PCG

The major genes that have been
associated with PCG to date are
summarized in Table 1. The majority of
familial cases of PCG exhibit an
autosomal
recessive
pattern
of
inheritance,8 ie both parents carry a
copy of the mutant gene but do not
themselves show signs of the condition.
The first genetic site or locus
associated with PCG (GLC3A) was
discovered on the p arm of
chromosome 2 (location 2p31). Of the
original families studied, a significant
proportion of individuals mapped to
this locus.1,8 Subsequently, the human
cytochrome P4501B1 gene (CYP1B1)
was mapped to the critical region and is
a gene that is expressed in the
trabecular meshwork.9 Originally, three

different mutations were identified

within the CYP1B1 gene,9 viz., a
deletion of 136 nucleotides in exon III,
an insertion of an extra cytosine
nucleotide in exon II, and a larger
deletion affecting the one end of exon
III. The effect of all three mutations was
to remove certain combinations of
amino acids from the resulting protein.
Subsequently,
several
further
abnormalities of the CYP1B1 gene have
been identified. First, a new-born infant
presented with buphthalmos and an
opaque cornea and these alterations
were associated with a change in one
nucleotide of the DNA, viz., a novel
cytosine to thymine transition at codon
355, this change resulting in a protein
shortened by 188 amino acids.10 Second,
extensive clinical and genetic variation
has been observed in Indian patients
with PCG, the predominant genetic
change being a substitution of one
amino acid by another at codon 368
within the CYP1B1 gene.11
Soon after the identification of the
first gene linked to PCG, eight families
were found that exhibited no linkage to
the 2p31 region. Hence, a second locus
(GLC3B) was postulated and appeared
to be located on the short arm of
chromosome 1 (1p36 -36.1).8 In
addition, there are at least four families
not linked to either of these loci

suggesting at least one more gene

linked to PCG. Recently, a locus
(GLC3C) has been found at 14q24.3 but
at the time of writing the genes
associated with this and the GLC3B
locus have not been definitively
identified.
A major gene linked to primary open
angle glaucoma (POAG) is the gene
coding for the protein myocilin and
this gene locus (GLC1A) probably
accounts for 10-33% of juvenile cases.
Abnormalities of the myocilin gene
have been detected in families in
which different members develop
either PCG or POAG. In particular,
homozygous mutations in intron 2 of
the myocilin gene appear to be
involved both in PCG and POAG. A
more detailed discussion of the
myocilin gene can be found in
Armstrong and Smith.2

How could genes cause PCG?

There have been several theories as to
how genes might be implicated in the
pathogenesis of PCG. First, PCG may
result from the persistence of a
membrane (Barkans membrane) over
the inner surface of the anterior
chamber angle. This explanation is
now thought to be unlikely as there is
no strong evidence for the existence of

CONGENITAL GLAUCOMA

cells. Aberrant development or

transport of materials within the
microtubules of cells of the trabecular
meshwork could then directly lead to
increased IOP.

not achieve vision better than 20/50

(Snellen). Patients with PCG will
require follow up care for the rest of
their lives as subsequent elevation of
IOP can occur at any age.

Treatment of PCG

Discussion and conclusions

In most cases, PCG is managed by

surgery. Medical care may be used to
manage the condition prior to surgery
and to control pressure changes in the
eye during surgery. The surgical
intervention is designed to eliminate
the resistance to aqueous outflow
caused by the structural abnormalities
within the anterior chamber angle.
Goniotomy is one procedure that can be
used and involves the removal of tissue
with the aid of a goniolens, thus
relieving the compressive forces on the
anterior part of the uvea and the
trabecular network. This procedure
eliminates any resistance caused by
incomplete development of the inner
trabecular network. Another approach
is to use trabeculotomy in which the
canal of Schlemm is identified by
dissection
and
the
trabecular
meshwork removed by passing a probe
into the canal. This procedure can be
carried out if the cornea is cloudy or
opaque, an advantage over gonioscopy.
The success rate for both procedures is
about 80%. The prognosis is far poorer
in infants with elevated IOP and if an
opaque cornea is present at birth, while
best outcomes are often achieved if the
surgery is carried out between the
second and the eighth week of life. If
these procedures fail, usually after
several attempts, then a filtering
procedure is usually carried out
involving trabeculectomy. If all of these
methods fail then the use of shunts or
the destruction of the ciliary body have
been advocated.
Intensive aftercare is usually required
after these procedures and often
involves several further examinations
under anaesthetic. Complications of the
surgery
may
involve
hyphema
(bleeding into the anterior chamber),
infection, lens damage, and uveitis but
the risks of the anaesthetic are generally
regarded as the most serious possible
complication. The corneal swelling
may persist for several weeks even after
successful reduction of IOP. Reduction
in IOP is often an important indicator of
subsequent visual quality of life,
substantially better vision being
observed in patients whose pressures
remain no higher than 19mmHg.
However, nearly 50% of children will

Recent studies have emphasised that a

significant proportion of glaucoma
cases are genetic and that genetically
based forms of the disease are
heterogenous. At least seven major
genetic loci have now been identified in
glaucoma. Five of these loci, designated
GLC1A to GLC1E, are associated with
forms of primary open angle glaucoma
and two loci, designated GLC3A and
GLC3B associated with PCG. In
addition, a number of loci have been
implicated in the secondary glaucomas
(GLC2).
One of the objectives of the molecular
biological study of glaucoma is to
establish how the disease develops as a
result of the production of aberrant gene
products. Many of the genes associated
with glaucoma code for proteins that
are likely to be directly or indirectly
involved in the development and/or
function of cells within the trabecular
meshwork. The identification of
specific defects in these genes is likely
to lead to a better understanding of the
mechanisms involved in PCG and
glaucoma in general and to the
development of alternative therapies to
surgery. The CYP1B1 gene in particular,
which is linked to congenital glaucoma,
and is expressed in the trabecular
meshwork, codes for a member of the
cytochrome P450 group of proteins.
These iron-binding proteins constitute a
family of enzymes involved in the
processes of xenobiotic metabolism,
growth, and development.
The
discovery of the CYP1B1 gene in PCG
emphasizes
the
importance
of
abnormalities in the molecular
structure of proteins expressed in cells
of the trabecular network as a cause of
PCG. The identification of specific
genetic defects leads to the possibility
of more widespread screening for PCG
especially in affected families and
hence,
the
possibility
of
the
identification of asymptomatic carriers
of the disease. Early identification of 'at
risk' parents may then enable earlier
detection of PCG and intervention in
the infant.

References
See www.optometry.co.uk/references

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this
membrane
during
normal
development. Second, PCG could be
caused by a failure of cleavage of the
mesenchyme to form the iridocorneal
angle. This theory can also be
discounted since there is considerable
doubt as to whether this cleavage
actually occurs during development.
Third, PCG could be caused by a failure
of apoptosis (programmed cell death)
during angle development. However,
apoptosis has been rarely observed
during normal development of the
anterior chamber angle in the human
eye. Fourth, the CYP1B1 gene may be
involved in a process within the cornea
that regulates the secretion of fluid;
production of excess fluid could then
result in high IOP and PCG. Fifth, PCG
could be due to a failure of
differentiation or a change in
differential growth rates affecting cells
within the anterior chamber angle.
There are histological studies of PCG
that
describe
the
tissue
as
undifferentiated or lacking the typical
appearance of trabeculae with spaces
between them, especially in the outer
layers.
Recent genetic studies offer some
support for the fifth hypothesis, ie,
there is a problem in the development
of the anterior chamber angle. In many
of the hereditary forms of PCG,
especially those with a strong pattern
of inheritance, the primary defect is in
the CYP1B1 gene. This gene is
expressed in the tissue of the anterior
chamber and mutations of the gene
interfere both with the integrity of the
protein and with its ability to adopt a
normal shape and as a consequence to
bind iron containing compounds.12
CYP1B1 is also involved in the normal
development and function of the eye
by metabolising essential molecules
used in the signalling pathway. There
is, however, a yet unknown sequence
of events that may link changes in the
CYP1B1 gene to the final stages of
anterior chamber development. In
addition, the relationship between
mutations of the CYP1B1 gene and PCG
remains
controversial
since
experimental (transgenic) mice in
which the gene is deactivated (knockout mice) do not develop a typical
glaucoma phenotype.13
Recent studies suggest that the
myocilin gene may also be involved in
PCG. The exact function of the protein
is currently unknown but it is a
cytoskeletal protein and is probably
involved in the development of
microtubules within ciliated epithelial