Variants in RNU4-2 or RNU6 paralogs account for 2% of cases with non-syndromic autosomal dominant retinitis pigmentosa in a large French

Variants in RNU4-2 or RNU6 paralogs account for 2% of cases with non-syndromic autosomal dominant retinitis pigmentosa in a large French | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Variants in RNU4-2 or RNU6 paralogs account for 2% of cases with non-syndromic autosomal dominant retinitis pigmentosa in a large French Isabelle Audo, Julien Navarro, Lorenzo Bianco, Alessio Antropoli, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9032551/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Rod-cone dystrophy, also known as retinitis pigmentosa (RP), is a genetically heterogeneous group of retinal disorders with progressive rod then cone photoreceptor loss, leading to severe visual impairment. Autosomal dominant RP has been associated with about thirty genes, while approximately 10% of our French autosomal dominantRP cohort remain genetically unsolved. Recently, several variants in small nuclear RNA (snRNA) genes have been identified in cases with autosomal recessive and autosomal recessive neurodevelopmental disorders as well as autosomal dominant RP. These snRNAs undergo post-transcriptional modifications and, in association with proteins and other snRNAs, assemble into small nuclear ribonucleoproteins that are components of the spliceosome. By performing genome and direct Sanger sequencing, combined with a candidate gene approach, we identified heterozygous variants in RNU4-2 and RNU6 paralogs in eight unrelated non-syndromic autosomal dominant RP families, which co-segregated with the phenotype in available family members. RNU4-2 and RNU6 encode U4 and U6, snRNA, respectively, forming with U5, the tri-sn ribonucleoprotein (RNP) complex, representing the core of the major spliceosome. Interestingly, variants in autosomal dominant RP cases cluster in distinct locations than variants implicated in neurodevelopmental disorders, affecting regions important for tri-snRNP complex assembly with PRPF3, PRPF8 and PRPF31, also implicated in RP. Together, our findings revealed that 2% of our genetically solved cases with autosomal dominant RP carry variants in RNU4-2 or RNU6 paralogs. This represents 6% of all cases having variants in genes coding for the multisubunit complex, highlighting the importance of screening snRNA genes in cases of RP. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Rod-cone dystrophy, also known as retinitis pigmentosa (RP), is a progressive rod-cone degeneration and represents the most frequent form of inherited retinal disorders (IRDs), with a prevalence of around 1 in 4,000 individuals 1 . Clinically, patients experience night blindness due to rod dysfunction, followed by progressive visual field constriction due to secondary cone degeneration and eventually visual acuity loss in more severe cases resulting in complete blindness 2 .All modes of inheritance are possible for RP, with autosomal RP comprising 30–40% of cases 3 and about 20-30 genes defects or loci identified (https://retnet.org/summaries and https://retigene.erdc.info) 4-6 . Genetic variants in genes important for splicing represent a major cause of autosomal dominant RP 7 . Indeed, epidemiological studies from us and others identified variants in pre-mRNA splicing factorsunderlying autosomal dominant RP such as PRPF31 (MIM:606419) 8-10 , PRPF3 11 [MIM: 607301], PRPF4 12 [MIM:607795], PRPF6 13 [MIM: 613979], PRPF8 14 [MIM:607300]), the RNA helicases SNRNP200 15 [MIM: 601664]) and RP9 16 [MIM: 1801018010]). Pre‑mRNA splicing factors physically and functionally organize the U4, U5, and U6 small nuclear (sn)RNAs into the tri- small nuclear ribonucleoprotein (snRNP) complex and then remodel them to form the catalytic core of the spliceosome 17 . While PRPF31, PRPF3 and PRPF8 are essential for the assembly and stability of the pre-mRNA splicing machinery, as they help to maintain the integrity of the U4/U6.U5 tri-snRNP complex 18-21 , SNRNP200 represents another U4/U6.U5 snRNP component that is required for unwinding U4/U6 snRNAs during the spliceosome activation and for the disassembly of the spliceosome 15 . PRPF31, PRPF3, PRPF4 and RP9 (PAP1) were found to be U4/U6 specific while PRPF6, PRPF8 and SNRNP200 are specific of U5 snRNP 21-24 . Interestingly, several variants in snRNA genes have recently been identified in autosomal recessive and autosomal dominant cases of neurodevelopmental disorders but also autosomal dominant RP 25,26 . To date, a conclusive molecular diagnosis for RP can be reached in ~70% of cases. 27 A review published in 2014 estimated that approximately 25% of autosomal dominant RP cases remain genetically unsolved. 28 Since then, advances in next generation sequencing have led to the identification of new genetic defects, solving further cases of autosomal dominant RP (https://retnet.org/summaries and https://retigene.erdc.info) 4-6 . We estimated that about 10% of cases remain genetically unsolved in our French cohort of autosomal dominant RP cases. Recent advancements in sequencing technologies and bioinformatic tools combined with candidate gene approaches and functional studies are aiming at solving the missing gene defects. Thus, the aim of the study herein was to identify the missing gene defects in genetically unsolved autosomal dominant or sporadic cases with RP using genome and direct Sanger sequencing, combined with a candidate gene approach. Results Identification of RNU4-2 , RNU6-1 , RNU6-2, RNU6-8 and RNU6-9 variants in a French cohort with autosomal dominant RP By performing genome sequencing (GS) in 4 genetically unsolved autosomal dominant RP families, applying filtering based on the allele frequency, in silico prediction programs, and segregation in the sequenced family members (see Methods), still ~15,000-43,000 heterozygous candidate disease causing variants remained. Subsequently, variants identified in genes being previously (Table 1) and more recently associated (Table 2) with RP were investigated in more details. 26 Using this prioritization method, we identified the following variants in the snRNA genes: the n.55_56insG (F581) and the n.56_57insG (F1545) in RNU6-1, the n.55_56insG (F4754) in RNU6-8 and the n.56T>C (F6788) in RNU4-2 (Table 2). Although different variants in RNU1 , RNU2 , RNU4 , RNU5 and RNU6 (Supplementary table 1) paralogs were identified in other unsolved families, they were not considered to be pathogenic due to their high frequency in gnomAD v3.1.2, e.g. in one remaining unsolved adRP family 260 variants were annotated in all snRNA paralogs but none had an allele frequency ≤0.005. For family F581, GS was performed in the affected women, CIC00914 and her affected daughter, CIC13399. More than 16,400 heterozygous variants were identified co-segregating with the phenotype in both affected cases. One of the putative candidate variants was located in SNRPN , a gene associated with Prader-Willi Syndrome, which was however not considered to be pathogenic due to its high prevalence in the general population and inconsistency with the RP phenotype (Tables 1 and 3). Subsequently, the candidate gene 26 approach identified the n.55_56insG variant in RNU6-1, co-segregating with the phenotype in available family members (Table 2, Figure 1) For Family F1545, GS was performed in the affected women, CIC03564 and her asymptomatic sister, CIC10996. More than 43,550 heterozygous variants were identified, co-segregating with the assumed phenotype of this family. One of the putative candidate variants was located in CCR5 , a gene not expressed in the retina and associated with phenotypes such as diabetes mellitus, insulin-dependent, resistance to hepatitis C virus, susceptibility/resistance to human immunodeficiency virus infection, and susceptibility to West Nile virus, not explaining the RP phenotype of our index subject (Tables 1 and 3). Subsequently, the candidate gene 26 approach identified the n.56_57insG variant in RNU6-1 in the index and asymptomatic sister (Table 2, Figure 1). For Family F4754, GS was performed in the affected male, CIC08435 and his affected brother, CIC10249. More than 13,100 heterozygous variants were identified. One of the putative candidate variants was located in SNRNP200 , an excellent candidate gene, implicated in adRP 15 , which was however absent in the affected brother, and thus excluded as disease-causing in this family. Subsequently, the candidate gene 26 approach identified the n.55_56insG variant in RNU6-8 in the index and affected brother (Table 2, Figure 1). For Family F6788 GS was performed in the affected women, CIC11764 and her affected mother, CIC11765. More than 15,533 heterozygous variants were identified, co-segregating with the assumed phenotype of this family. Two putative candidate variants were identified, one heterozygous variant in CEP290 29 and one heterozygous variant in NMNAT1 30 , both of which are well-established genes implicated in IRDs, but known to follow an autosomal recessive mode of inheritance. Since this mode of inheritance was not consistent with that observed in Family F6788 (Figure 1), and no second heterozygous variant in trans was detected in both genes, these variants were excluded as disease-causing in this family. Subsequently, the candidate gene 26 approach identified the NR_003137.2 n.56T>C variant in RNU4-2 in the index and affected mother (Table 2, Figure 1). Subsequent Sanger sequencing of an unsolved RP cohort taking into account all RP-associated snRNA genes, genetically solved 4 further families with autosomal dominant RR (Figure 1) harboring heterozygous variants in the snRNA genes: the n.55_56insG (F1111) in RNU6-9 , the n.55_56insG (F4368) in RNU6-2 and the n.18_19insA (F5387 and F6085) in RNU4-2 (Fig.1). These variants co-segregated with the phenotype following an autosomal dominant mode of inheritance (Fig. 1). All variants were absent from the general population (Genome Aggregation Database v4.1.0 database) and predicted to be pathogenic using the annotation of the American College of Medical Genetics and Genomics guidelines (Table 2) 31 . RNU4-2 , RNU6-1 , RNU6-2, RNU6-8 and RNU6-9 variants are predicted to alter the binding of the U4/U6 duplex with the splicing factors PRPF3, PRPF6, PRPF8 and PRPF31 The RNU4-2 variant n.18_19insA inserts a nucleotide in the loop created at the junction of the stem I, stem II and 5’ stem loop and also the n.56T>C variant is localized in this same loop. As previously performed, in silico modeling predicted that both variants will extend the size of the junction and alter the orientation of the stems 26 . These structural changes are predicted to compromise the overall stability of the U4/U6 duplex 26 . The RNU6 paralogous variants n.55_56insG and n.56_57insG insert a nucleotide in the stem I. Both variants are predicted to extend the stem I by pairing three additional nucleotides. As previously shown the extension of stem I significantly reduces the size of the junction and alters the orientation of the stems 26 . These changes in the secondary structure are predicted to disrupt the correct binding of the U4/U6 duplex 26 . Interestingly, the variants identified herein are located in regions of U4 and U6 interacting with PRPF3 and PRPF31 via hydrogen bonds (Fig. 2). Subsequently, other factors will bind to stabilize the complex. Thus, the identified variants in RNU4-2 and RNU6 paralogs will disrupt the overall assembly of the U4/U6.U5 tri-snRNP and then seriously impact the function of the entire splicing complex (Fig. 2). Patients with variants in RNU4-2 , RNU6-1 , RNU6-2, RNU6-8 and RNU6-9 reveal adRP Table 2 reports clinical findings in probands and available family members carrying variants in RNU4-2 or RNU6 paralogs identified in this study. Family pedigrees are displayed in Fig. 1 and multimodal retinal imaging of the right eyes presented in Fig. 3. All families were from French descent beside one (F6085) originating from Madeira. Proband cases all reported family history suggesting adRP. For one pedigree (F1545), one sister of proband (CIC10996) carried the likely pathogenic variant in RNU6-1 but was said to be asymptomatic but was not available for proper examination. In addition, one proband (CIC11764) had more advanced disease than her mother (CIC11765) only mildly affected at the time of her daughter’s diagnosis suggesting a variable expressivity in this case. Besides, 2/8 subjects with a history of thyroid inflammatory disease and on case with pseudotumor of one eye, none had specific systemic conditions. Age at time of diagnosis was available for 5/8 probands with mean age being 20.6±6.95. Night vision disturbances were the first symptom reported by all probands with at least half of the cases with childhood onset. Age at time of examination was 47.4±14.6. Mean best corrected visual acuity was 0.33 LogMar on the right and 0.31 on the left. There was no consistent refractive error across cases. The Lanthony 15-desaturated hue color vision test had been performed in 5/8 probands and showed a tritan defect for 3/5. All subjects aged 50 or more had a reduced visual field at the binocular III4e to the 20 central degrees. All subjects within their fifties either had posterior subcapsular cataract or had undergone cataract surgery. Fundus examination showed a distinct marked chorioretinal atrophy including the peripapillary area with pale disc and narrowed retinal vessels in 5/8 cases with multimodal imaging in keeping with relative central macula preservation (Fig. 3). In addition, 5/8 cases and 1 sibling had a history of cystoid maculopathy. Discussion Our work described herein genetically solved 2% families with autosomal dominant RP harboring variants in the U4 and U6 small noncoding nuclear RNA by a combination of GS, candidate gene 26 and Sanger sequencing approaches. Variants in these RNA genes were most likely missed before since gene defect identification largely focused on protein coding genes. However, splicing has been shown to play a crucial role for the proper functioning of the retina 32 and thus components important for the splicing machinery represent excellent candidate genes to be implicated in retina pathology. Indeed, nearly all human genes contain introns, which are excised during pre-mRNA splicing as part of post-transcriptional processing 33 . Small noncoding nuclear RNAs (U1, U2, U4, U5, and U6) and several associated proteins, such as PRPF31, PRPF8, PRPF3, SNRNP200 and PRPF6, known to be associated with autosomal dominant RP, belong to the spliceosome multisubunit complex catalyzing this reaction 34 . These findings support the variants in RNU4 and RNU6 paralogs identified herein and by Ouinodoz et al. 26 as strong candidate for disease-causing variants underlying autosomal dominant RP. All cases carrying these variants in our study recognized a family history of autosomal dominant RP with one occurrence of possible incomplete penetrance and one with variable expressivity. Clinical characteristics include onset of symptoms in early childhood for most cases and retinal alterations consistent with the diagnosis of RP with a predominance of chorioretinal atrophy and cystoid maculopathy. Interestingly, several very recent studies highlighted heterozygous disease-causing variants in these RNA genes, such as RNU4-2 but also RNU2-2, RNU5B-1 and RNU5A-1 , in severe neurodevelopmental disorders (NDD) 35-44 . None of these features were present in our patients with autosomal dominant RP. In the majority of cases with NDD the variants occurred de novo (e.g. 37 ). Interestingly, although DNA for genetic testing was not available from all family members of our RP cohort, the family pedigrees clearly demonstrated that the variants were inherited in an autosomal dominant manner (Fig. 1). Indeed, all variants co-segregated with an autosomal dominant mode of inheritance in all family members available for genetic testing (e.g. Fig. 1, F6788, F581), except in one (Fig. 1, F1545, CIC10966). In the latter one, the index subject CIC03564 of family F1545 had typical RP with night blindness since childhood, while her older sister, CIC10996 was reported to be asymptomatic and was aged 80 at last report, although not available to us for ophthalmic assessment, suggesting incomplete penetrance, a finding also reported with splicing factors such as PRPF31 . 9 Furthermore, in F6788, proband CIC11764 showed more advanced disease than her mother suggesting variable expressivity. Remarkably, pedigree analysis revealed that 27 subjects were females out of the 39 affected cases in our 8 RP families. This was especially striking in F5387 (Fig. 1), where only 1 male out of 8 females was affected. Similarly, in individuals with NDD carrying a genetic variant in RNU4-2 , the variant was consistently found on the maternal allele. 38 This pattern may reflect negative selection in the male germline if RNU4-2 and RNU6 paralogs are critical for spermatogenesis. Alternatively, it could result from imprinting, whereby variants on a highly expressed paternal allele lead to embryonic lethality, while those on a less active maternal allele are compatible with survival but result in NDD. 38 Our findings are distinct from the study by Quinodoz et al., 26,45 There, RNU4-2 and RNU6 variants were frequently reported as de novo with incomplete penetrance leading to RP. There was also no sex-specific negative selection during gametogenesis or at the embryonic state. 26,45 A more precise clinical investigations of all family members of our and the families reported in the study by Quinodoz et al., 26 may shed light on these observed differences in patients with RP. Of importance, variants in the RNA genes leading to autosomal dominant RP cluster in distinct regions as variants leading to neurodevelopmental disorders (Fig. 4). Autosomal dominant RP-variants affecting U4 and U6 are located close to the three-way junction, a site that is crucial for the U4/U6.U5 tri-snRNP complex assembly with PRPF3, PRPF8 and PRPF31 (Figs. 2 and 4). On the other side, variants reported in patients with neurodevelopmental disorders affect the stem III and T-loop, which position the U6 ACAGAGA box at the 5’splice site recognition which may have distinct functional consequences leading to a distinct phenotype 37 . Due to the interaction of U5 with the tri-snRNP complex, RNU-5 reflects also a good candidate to be mutated in cases with RP. However, none of our GS and genetically unsolved families with RP, harbored predicted disease-causing variants in these RNA paralogs. Further GS needs to be applied to all unsolved cases with RP and sequencing data analyzed not only focusing on protein coding genes. Our findings helped to genetically solve 8 additional families of our French cohort of 395 autosomal dominant RP families. As found in other studies, in our cohort variants in RHO (102 cases) 46 represents the major gene defect underlying a autosomal dominant RP, followed by PRPH2 (59) 47 , PRPF31 (59 cases) 8 and RP1 (48 cases) 10 (Fig. 5). Besides the relatively high prevalence of disease-causing variants in the pre-mRNA splicing factor PRPF31 , we identified in our cohort 23, 20 and 13 autosomal dominant RP families with disease-causing variants in PRPF8 , PRPF3 , SNRNP200 respectively and 5 possible disease-causing variants in PRPF6 . Together, adding the findings presented herein, variants in RNU4-2 and RNU6 paralogs account for 2% of our solved cases with autosomal dominant RP and variants in genes important for the spliceosome multisubunit complex represents 6% of all autosomal dominant RP cases (Figure 5). These findings along with those of Quinodoz et al., 26 outline the importance of major components of the multisubunit spliceosome complex including small noncoding nuclear RNAs for photoreceptor homeostasis. The reason why spliceosome defects such as those discussed in the present work, lead to a retina-restricted phenotype, namely a rod-cone dystrophy, although pre-mRNA splicing is a ubiquitous phenomenon, is still a matter of debate. The retina is associated with high splicing demand and expresses very high levels of spliceosomal snRNAs and processes more pre-mRNA than other tissues 48 . Considering the high metabolic activity and protein turnover in photoreceptors, even a mild reduction in splicing efficiency would disproportionately affects retinal cells. In addition, previous works have suggested a selective vulnerability of retinal transcripts to mis-splicing in case of spliceosome defects, while global splicing may be preserved 49 . Furthermore, many genes expressed in photoreceptor may rely on alternative splicing to generate retina-specific isoforms. Several studies have documented the mis-splicing profile associated with PRPFs pathogenic variants with a widespread effect on phototransduction, ciliary proteins and RNA processing 50-52 . Similarly, studies on retinal organoids and retinal pigment epithelial cells derived from patients carrying snRNA gene defects may shed further light in their pathogenic mechanisms and may help design therapeutic interventions. Materials and Methods Participants and clinical assessment Participants were identified from a large historical cohort of individuals affected with RP who underwent comprehensive ophthalmic examinations, including standard-of-care retinal imaging and functional assessments as previously described 53 . All participants had long remained genetically unsolved and underwent genome sequencing (GS), exome sequencing (ES), or targeted candidate gene screening. All 7 probands were identified at the National Refence Centre for rare retinal diseases REFERET of Quinze-Vingts Hospital (Paris, France) within a cohort of autosomal dominant RP patients. The study protocol adhered to the tenets of the Declaration of Helsinki and received approval from the local ethics committees (Committees of Protection of Persons Ile de France V, Project number 06693, N◦EUDRACT 2006-A00347-44, 11 December 2006). Written, informed consent was obtained from all participants prior to their inclusion in this study. Genetic analyses, variant prioritization, and in silico prediction tools Blood samples were obtained from probands, and when possible, other family members. Total genomic DNA was extracted from peripheral blood lymphocytes by standard procedures as performed before. 53 GS was performed on 4 families (Fam581, Fam1545, Fam4754 and Fam6788) (Integragen, Evry, France) using a NovaSeq600 instrument, as previously described. 28 The sequencing data processing was done as previously described. 5 Briefly, we used bwa 0.7.17 (https://doi.org/10.1093/bioinformatics/btp324) for the mapping onto the hg38 reference genome, GATK 4.1.7.0 54 for variant calling step and ANNOVAR 55 for variant annotation. The annotation includes scores from many in-silico prediction programs such as CADD 56 , AlphaMissense 57 , REVEL 58 , BayesDel 59 , and MetaRNN 60 , SpliceAI 61 , Pangolin. 62 Variants with a minor allele frequency ≤ 0.005 in the Genome Aggregation Database v3.1.2 (https://gnomad.broadinstitute.org) were prioritized if they were classified as pathogenic, likely pathogenic, or of uncertain significance according to the American College of Medical Genetics and Genomics (ACMG) guidelines 31 , and if they were heterozygous and segregated within affected family members. In cases where variant prioritization based on allele frequency, predicted pathogenicity, and familial segregation did not yield credible candidates, a systematic review of recent literature was conducted. This bibliographic search specifically targeted genes newly associated with dominant retinal diseases in articles and preprints published within the last 24 months. Among the identified candidates, a key publication highlighted the involvement of two snRNAs in the spliceosome. Consequently, all spliceosomal snRNA genes were considered as candidates (supp table). These genes were subsequently analyzed to detect rare variants in our cohort. In all cases, direct Sanger sequencing was performed to validate the identified variants on the probands and perform segregation analysis on all available family members. Direct Sanger sequencing was also applied to screen our cohort of unsolved cases (~300 cases) for all RNU4-1 (NR_003925.1), RNU4-2 (NR_003137.2) , RNU6-1 (NR_004394.1) , RNU6-2 (NR_125730.1) , RNU6-7 (NR_104084.1) , RNU6-8 (NR_104088.1)and RNU6-9 (NR_104080.1)genes. Details regarding primers and PCR and Sanger sequencing conditions will be available on request. We used RNAfold WebServer 63 with default parameters to predict the impact of variants in the U4/U6 secondary structure and RNAcanvas v1.1.16 64 to draw it. We loaded the human U4/U6.U5 tri-snRNP 65 PDB file into PyMOL 2.5 for 3D modeling. Declarations DATA AVAILABILITY All data and materials will be supplied upon request. ACKNOWLEDGMENTS The authors are thankful to the patient and family members participating in the study and clinical staff from the Reference Center for rare diseases REFERET at Quinze-Vingts Hospital. DNA samples included in this study originate from NeuroSensCol DNA bank (PI: I Audo, partner with Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, INSERM and CNRS). FUNDING STATEMENT This research was funded by Fondation Voir et Entendre (C.Z.), by French state funds managed by the Agence Nationale de la Recherche within the Investissements d’Avenir program (ANR-11-IDEX-0004-0), IHU FOReSIGHT (ANR-18-IAHU-0001 to I.A. and C.Z.) and ANR-23-CE17-0014-01 RP_SOLVEANDCURE to C.Z. and I.A.), LABEX LIFESENSES (ANR-10-LABX-65 to I.A. and C.Z.) and Retina France (I.A. and C.Z. ), Foundation Fighting Blindness center grant (C-CMM-0907-0428-INSERM04 to I.A. and C.Z.), grant (BR-GE-0619-0761-INSERM to I.A. and C.Z.), UNADEV (Union Nationale des Aveugles et Deficient Visuels to I.A. and C.Z.) in partnership with ITMO NNP/AVIESAN (alliance nationale pour les sciences de la vie et de la santé) for research in visual disorders and the Fondation de l’oeil (Prix de la Fondation de l’oeil I.A. and C.Z.). AUTHOR CONTRIBUTIONS Conceptualization: J.N., I.A., C.Z.; Writing-original draft: J.N., I.A., C.Z.; Writing-review & editing: J.N., I.A., C.Z.; Data curation: J.N., L.B., A.Antro., C.C., A.Anto., C.A., S.M.-S., C.L.-C., R.A., A.B., V.S., J.S. I.M. Formal analysis: L.B., J.N., C.C., A.Anto., A.Antro., C.A., E.M.P., E.A.P., S.E.S., V.S., V.K., L.M., A.R., B.B., J-A.S.. . Supervision: C.Z., I.A; Funding acquisition: C.Z., I.A. ETHICS DECLARATION All institutions involved in human participant research received national or local IRB approval (Committees of Protection of Persons Ile de France V, Project number 06693, N◦EUDRACT 2006-A00347-44, 11 December 2006). Written informed consent was obtained from all individuals. All studies were carried out in accordance with the declaration of Helsinki. CONFLICT OF INTEREST The authors have no competing financial interest in this study. References Berger W, Kloeckener-Gruissem B, Neidhardt J. 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HGVS .p Zygosity ACMG Criteria ACMG Classification gnomAD v3.1.2 allele frequency gnomAD v3.1.2 allele count Discarded reason F581 CIC00914 affected female 16464 SNRPN (MIM: 182279) NM_001378251.1 chr15:24886591T>C c.-738+2T>C p.(?) het PM2 VUS 6.11E-3 930 Too frequent in gnomAD v3.1.2 gene associated with Prader-Willi syndrome (MIM:176270) and Angelman syndrome (MIM: 105830 not compatible with RP phenotype CIC11339 affected daughter het F1545 CIC03564 affected female 43552 CCR5 (MIM: 601373) NM_001394783.1 chr3:46373205A>T c.303T>A p.(Cys101*) het PM2, BS2 VUS 8.475E-4 129, 6 ho Gene not expressed in retina; gene associated Diabetes mellitus, insulin-dependent (MIM:612522), Hepatitis C virus, resistance to (MIM: 609532), HIV infection, susceptibility/resistance to (MIM: 609423) and West Nile virus, susceptibility to (MIM: 610379), not compatible with RP phenotype CIC10996 Asymptomatic sister n.a. n.a. n.a. n.a. n.a. n.a. ho ref n.a. n.a. n.a. n.a. n.a. F4754 CIC08435 affected male 13107 SNRNP200 (MIM: 601664) NM_014014.5 chr2:96292971C>T c.2160+1G>A p.(?) het PM2, PVS1, BS4 VUS Absent n.a. Absent in affected brother CIC10249 affected brother Ho ref n.a. n.a. n.a. n.a. F6788 CIC11764 affected female 15533 CEP290 (MIM: 610142) NM_025114.4 chr12:88055700A>T c.6836T>A p.(Leu2279*) het PVS1, PM2, PP5, PS3 pathogenic Absent n.a. Absence of second variant in trans; gene is not associated with autosomal dominant mode of inheritance CIC11765 affected mother Het CIC11764 affected female NMNAT1 (MIM: 608700) NM_022787.4 chr1:9982630G>A c.769G>A p.(Glu257Lys) het PS4, PM2, PP2, PP3, PP5 pathogenic 8.149E-4 124 Absence of second variant in trans; gene is not associated with autosomal dominant mode of inheritance CIC11765 affected mother Het *Relative low allele frequency in gnomAD v3.1.2, and/or pathogenic, likely pathogenic or variant of uncertain significance (VUS) according to ACMG (American college of Medical Genetics and Genomics) classification, heterozygous for the affected sequenced samples. het: heterozygous. ho ref: homozygous for the reference sequence. HGSV: Human Genome Variation Society. c.: coding sequence. p.: protein position. n.a.: not applicable. PVS1: pathogenic very strong. PS3: pathogenic strong (functional assays). PS4: pathogenic strong (frequently present in affected cases compared to control). PM2: pathogenic moderate (rare in gnomAD v3.1.2). PP2: pathogenic supporting (low tolerance for benign variants). PP3: pathogenic supporting (reported in clinical databases e.g. ClinVar). BS2: benign strong (reported in healthy adults). BS: benign strong (does not co-segregate with the phenotype in the family). Table 2: Pathogenic variants in RNU4-2 , RNU6-1 , RNU6-2, RNU6-8 and RNU6-9 leading to RP Variant ID Variant Description GRCh38 Gene Transcript Variant Number of families Allele count gnomAD v3.1.2 ACMG Criteria ACMG classification V1 NC_000012.12:g.120291885_120291886insT RNU4-2 NR_003137.2 n.18_19insA 2 0 PS3, PS4, PM2 pathogenic V2 NC_000012.12:g.120291848A>G RNU4-2 NR_003137.2 n.56T>C 1 0 PS3, PS4, PM2 pathogenic V3 NC_000015.10:g.67839990_67839991insC RNU6-1 NR_004394.1 n.55_56insG 1 0 PS3, PS4, PM2 pathogenic V4 NC_000015.10:g.67839989_67839990insC RNU6-1 NR_004394.1 n.56_57insG 1 0 PS3, PS4, PM2 pathogenic V5 NC_000019.10:g.1021576_1021577insG RNU6-2 NR_125730.1 n.55_56insG 1 0 PS3, PS4, PM2 pathogenic V6 NC_000014.9:g.32203214_32203215insC RNU6-8 NR_104088.1 n.55_56insG 1 0 PS3, PS4, PM2 pathogenic V7 NC_000019.10:g.893538_893539insG RNU6-9 NR_104080.1 n.55_56insG 1 0 PS3, PS4, PM2 pathogenic AMCG, American college of Medical Genetics and Genomics; V: variant Table 2: Clinical findings in patients carrying variants in RNU4-2 or RNU6 paralogs Subject # Family # Sex ancestry Medical history Ophthalmic history Age at time of diagnosis Age at time of examination Symptoms BCVA RE/LE refraction Kinetic visual field III4e HxV Color vision Fundus examination FAF SD-OCT CIC00914 F581 F French Nothing relevant Bilateral cataract surgery at 41 with capsulotomy 10 years later Bilateral cystoid maculopathy 11 48 Childhood onset night blindness 20/125 20/50 -1.50(-0.75)120° -1.25(-1)105 20°x20° NP Peripheral and peripapillary chorioretinal atrophy with coarse pigment migration Pale optic disc and narrowed retinal vessels Patchy loss of AF in the periphery and in the peripapillary area; increased AF at the central Relative preservation of the ONL at the central macula with irregular EZ and loss of the IZ CIC01811 F1111 M French Nothing relevant Bilateral cataract surgery at 37 and 38 Capsulotomy 10 years later NA 56 Early childhood onset night blindness 20/160 20/250 +1.25(-0.50)90° -0.25(-0.75)135° 15°x15° Tritan defect Peripheral and peripapillary chorioretinal atrophy with coarse pigment migration Pale optic disc and narrowed retinal vessels Perimacular vitreous traction Well demarcated loss of AF in the periphery including the peripapillary area; increased AF at the macula Relative preservation of the ONL at the central macula with irregular EZ and loss of the IZ CIC03564 F1545 F French High blood pressure Thyroiditis leading to hypothyroidy Pseudo tumor of the RE at 56 Bilateral cataract surgery at 59 Capsulotomy 5 years later 18 66 childhood onset night blindness 20/40 20/80 -3.5(-0.5)75° -2.5(-0.75)120° 20°x15° Tritan defect Peripheral and peripapillary chorioretinal atrophy with coarse pigment migration and perifoveal atrophy Pale optic disc and narrowed retinal vessels Large patchy loss of AF in the periphery including the peripapillary area; perifoveal loss of AF Thinning of the ONL, disorganized EZ, loss of IZ, intraretinal cyst CIC07828 F4368 F French Nothing relevant Bilateral cataract surgery at age 29 Capsulotomy 4 years later Bilateral cystoid maculopathy NA 33 Night blindness 20/20 20/20 +0.5(-0.50)10° +0.75(-1.25)75° 15°x15° with bitemporal islands NP Peripheral retinal changes with pigment migration Pale optic disc and narrowed retinal vessels Large patchy loss of AF in the periphery with a perifoveal ring of increased AF Relative preservation of the ONL and the hyper reflective bands at the central macula CIC08435 F4754 M French, from Britany Nothing relevant Cystoid maculopathy Subcapsular and nuclear cataract BE NA 59 Night blindness 20/32 20/32 -2.75 -2(-1.75)5° 20°x15° Normal RE Tritan defect LE Peripheral and peripapillary chorioretinal atrophy with subtle pigment migration and perifoveal atrophy Pale optic disc and narrowed retinal vessels Large patchy loss of AF in the periphery including the peripapillary area; perifoveal loss of AF Relative preservation of the ONL at the central macula with irregular EZ and loss of the IZ CIC10249, affected brother M Nothing relevant Cystoid maculopathy Subcapsular and nuclear cataract BE NA 53 Night blindness 20/63 20/50 -2.25(-3)20° -1.50(-3)160° 25°x25° with a peripheral island on the left Normal Peripheral and peripapillary chorioretinal atrophy with subtle pigment migration and patch of macular atrophy RE Pale optic disc and narrowed retinal vessels Large patchy loss of AF in the periphery including the peripapillary area; central loss of AF RE Relative preservation of the ONL at the central macula with central loss of the hyper reflective bands RE et preservation with intraretinal cysts LE CIC09384 F5387 M French Nothing relevant None 23 23 Teenage onset night blindness 20/20 20/20 Plano Plano 170°x20° Normal Beaten bronze appearance of the peripheral retina Slightly pale optic disc and narrowed retinal vessels Subtle changes in the periphery Perifoveolar ring of increased fluorescence Preservation of the ONL and the hyper reflective bands at the central macula CIC10536 F6085 F From Madeira Hashimoto thyroiditis leading to hypothyroidy Dyslipidemia Peritonitis Cataract surgery at 50 and 55 YAG 2 years later BE Cystoid maculopathy 30 57 Childhood onset night blindness 20/40 20/40 +1.50(-1)100° +0.75(-0.50)75° 20°x10° NA Peripheral retinal changes with pigment migration Pale optic disc and narrowed retinal vessels Patchy loss of AF in the periphery Perifoveolar ring of increased fluorescence Relative preservation of the ONL and the hyper reflective bands at the central macula with intraretinal cysts BE CIC11764 F6788 F French, Northern France atopic dermatitis Cystoid maculopathy 21 32 Decreased visual field superiorly and mild night blindness 20/20 20/20 +2.50(-1.50)25° +2.50(-3)155° 170°x100° Altered superiorly Normal Few pigmentary changes in the periphery, normal optic disc and retinal vessels Patchy loss of AF predominant in the inferior periphery and temporally Increased FA in the periphery of the posterior pole Preservation of the ONL and the hyper reflective bands at the central macula with intraretinal cysts BE CIC11765, mother mildly affected F Kidney stones None 49 60 Childhood onset night blindness 20/15 20/20 +2.75(-1)180 +3.50(-1.75)150 170°x120° normal Subtle beaten bronze appearance in the periphery with very few pigments Diffuse subtle increased in AF in the periphery which appears granular Thinning of the ONL in the periphery, very few drusenoid changes, preservation of the entire outer retinal bands in the periphery BCVA: best corrected visual acuity; RE/LE: right eye/left eye; BE: both eye; HxV: horizontal by vertical; NA: not available; NP: not performed; FAF: fundus autofluorescence imaging; AF: autofluorescence; SD-OCT; spectral domain optical coherence tomography; ONL: outer nuclear layer; EZ: ellipsoid zone; IZ: interdigitation zone Additional Declarations No competing interests reported. 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16:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9032551/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9032551/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105149585,"identity":"192d2e06-8867-4c36-96db-8e0ea9093878","added_by":"auto","created_at":"2026-03-22 14:56:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31564,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVariants \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU4-2\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU6-1\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU6-8\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e and \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU6-9\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e leading to autosomal dominant RP and co-segregation analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe identified in eight unrelated non-syndromic autosomal dominant RP families heterozygous variants in \u003cem\u003eRNU4-2\u003c/em\u003e (n.18_19insA and n.56T\u0026gt;C) and \u003cem\u003eRNU6\u003c/em\u003e paralogs (n.55_56insG and n.56_57insG), which are part of small nuclear RNAs forming a tri-snRNP complex, located at the core of the major spliceosome. The initial variant identification was performed by GS (F6788, F581, F1545,and F4754). Samples highlighted in red were used for GS. Subsequently, Sanger sequencing was performed (F5387, F6085, F4368 and F1111). Co-segregation analysis was achieved by Sanger sequencing in all available family members. Square symbols represent males, round symbols represent females. Black and white represent affected and unaffected status respectively.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/2a278649d36545321cf02a68.jpg"},{"id":105149591,"identity":"c8e100cb-87e9-4033-8fb1-2fc517155bc4","added_by":"auto","created_at":"2026-03-22 14:56:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58463,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e3D modeling of the interactions of the U4 and U6 variants with PRPF31 and PRPF3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHydrogen bonds (yellow) show interactions between U4 and U6 nucleotides in variant positions with the side chains of amino acids in PRPF31 (left) and PRPF3 (right).\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/4337cc98eb064d24e1a9e828.jpg"},{"id":105149590,"identity":"531ca77e-0968-4b32-a5b9-6324fb95d6f3","added_by":"auto","created_at":"2026-03-22 14:56:27","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":60963,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMultimodal imaging of the right eye of probands and available family members carrying variants in \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU4-2\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e and \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRNU6\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e analogues\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eColor fundus photographs (left column, short wavelength fundus autofluorescence (FAF, medium column), spectral domain optical coherence tomography (SD-OCT, horizontal scan, right column). For five (CIC00914, CIC01811, CIC03564, CIC07828 and CIC08435) of the eight probands plus one affected brother (CIC10249) fundus examination showed a distinct marked chorioretinal atrophy including the peripapillary area with pale disc and narrowed retinal vessels while the other 3 probands (CIC09384, CIC10536 and CIC11764) plus one affected mother (CIC11765) had peripheral retinal changes and pigment migration without marked chorioretinal atrophy. FAF and SD-OCT revealed outer retinal alteration predominant in the periphery. Only three cases (CIC CIC07828, CIC09384 and CIC10536) had a perifoveal ring of increased autofluorescence in keeping with preserved outer retinal bands on SD-OCT while CIC11764, the mildest case of the series, had midperipheral increase in autofluorescence. Four cases had perifoveal loss of normal autofluorescence (CIC00914, CIC01811, CIC03564, and CIC08435) and one brother (CIC10249) displayed loss of central autofluorescence. Five/eight cases had a history of cystoid maculopathy.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/0be2346e00efeaef74e4e74c.jpg"},{"id":105149586,"identity":"ab12e560-04a0-4f28-ad0a-9109f810099e","added_by":"auto","created_at":"2026-03-22 14:56:26","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42031,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eU4/U6 duplex structure and variants found in autosomal dominant RP and neurodevelopmental disorders \u003c/strong\u003eautosomal dominant RP-variants (highlighted in red) affecting U4 and U6 (depicted in brown and blue, respectively) are located close to the three-way junction, while variants in nucleotides identified in patients with neurodevelopmental disorders (highlighted in yellow) affect the stem III and T-loop, the crucial region implicated in NDD is shaded light-yellow and encircled.\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/933ce7e53ef1396afbddaa64.jpg"},{"id":105727796,"identity":"d8df46ff-bc9b-4d2e-a265-5cabc126f19d","added_by":"auto","created_at":"2026-03-30 11:03:54","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":29358,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of gene defects in patients with autosomal dominant RP of a French cohort\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVariants in \u003cem\u003eRNU4-2 \u003c/em\u003eand\u003cem\u003e RNU-6\u003c/em\u003esnRNA genes were found in 2% of cases with autosomal dominant RP. This represents 6% of all cases with variants found in genes important for the spliceosome multisubunit complex.\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/51e1b0c915b3a3ce230c6979.jpg"},{"id":105730386,"identity":"e96cdcf6-5ba7-49a5-8e04-b886b2905dc5","added_by":"auto","created_at":"2026-03-30 11:24:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1522866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/ad4b8cb1-d246-4c47-9dc4-280413d6587a.pdf"},{"id":105563836,"identity":"2e0f1768-12af-43c1-8252-e40ea61b4cdb","added_by":"auto","created_at":"2026-03-27 12:47:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14628,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9032551/v1/290696079b0bbfaa39374a6f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Variants in RNU4-2 or RNU6 paralogs account for 2% of cases with non-syndromic autosomal dominant retinitis pigmentosa in a large French","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRod-cone dystrophy, also known as retinitis pigmentosa (RP), is a progressive rod-cone degeneration and represents the most frequent form of inherited retinal disorders (IRDs), with a prevalence of around 1 in 4,000 individuals\u003csup\u003e1\u003c/sup\u003e. Clinically, patients experience night blindness due to rod dysfunction, followed by progressive visual field constriction due to secondary cone degeneration and eventually visual acuity loss in more severe cases resulting in complete blindness\u003csup\u003e2\u003c/sup\u003e.All modes of inheritance are possible for RP, with autosomal RP comprising 30\u0026ndash;40% of cases\u003csup\u003e3\u003c/sup\u003e and about 20-30 genes defects or loci identified (https://retnet.org/summaries and https://retigene.erdc.info)\u003csup\u003e4-6\u003c/sup\u003e. Genetic variants in genes important for splicing represent a major cause of autosomal dominant RP\u003csup\u003e7\u003c/sup\u003e. Indeed, epidemiological studies from us and others identified variants in pre-mRNA splicing factorsunderlying autosomal dominant RP such as\u003cem\u003e\u0026nbsp;PRPF31\u0026nbsp;\u003c/em\u003e(MIM:606419)\u003cem\u003e\u003csup\u003e8-10\u003c/sup\u003e\u003c/em\u003e\u003cem\u003e, PRPF3\u003c/em\u003e\u003csup\u003e11\u003c/sup\u003e [MIM:\u0026nbsp;607301], \u003cem\u003ePRPF4\u003c/em\u003e\u003csup\u003e12\u003c/sup\u003e [MIM:607795], \u003cem\u003ePRPF6\u003c/em\u003e\u003csup\u003e13\u003c/sup\u003e [MIM:\u0026nbsp;613979], \u003cem\u003ePRPF8\u003c/em\u003e\u003csup\u003e14\u003c/sup\u003e [MIM:607300]), the RNA helicases \u003cem\u003eSNRNP200\u003c/em\u003e\u003csup\u003e15\u003c/sup\u003e [MIM: 601664]) and \u003cem\u003eRP9\u003c/em\u003e\u003cem\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/em\u003e [MIM: 1801018010]). Pre‑mRNA splicing factors physically and functionally organize the U4, U5, and U6 small nuclear (sn)RNAs into the tri- small nuclear ribonucleoprotein (snRNP) complex and then remodel them to form the catalytic core of the spliceosome\u003csup\u003e17\u003c/sup\u003e. While PRPF31, PRPF3 and PRPF8 are essential for the assembly and stability of the pre-mRNA splicing machinery, as they help to maintain the integrity of the U4/U6.U5 tri-snRNP complex\u003csup\u003e18-21\u003c/sup\u003e, SNRNP200 represents another U4/U6.U5 snRNP component that is required for unwinding U4/U6 snRNAs during the spliceosome activation and for the disassembly of the spliceosome\u003csup\u003e15\u003c/sup\u003e. PRPF31, PRPF3, PRPF4 and RP9 (PAP1) were found to be U4/U6 specific while PRPF6, PRPF8 and SNRNP200 are specific of U5 snRNP\u003csup\u003e21-24\u003c/sup\u003e. Interestingly, several variants in snRNA genes have recently been identified in autosomal recessive and autosomal dominant cases of neurodevelopmental disorders but also autosomal dominant RP \u003csup\u003e25,26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTo date, a conclusive molecular diagnosis for RP can be reached in ~70% of cases.\u003csup\u003e27\u003c/sup\u003e A review published in 2014 estimated that approximately 25% of autosomal dominant RP cases remain genetically unsolved.\u003csup\u003e28\u003c/sup\u003e Since then, advances in next generation sequencing have led to the identification of new genetic defects, solving further cases of autosomal dominant RP (https://retnet.org/summaries and https://retigene.erdc.info)\u003csup\u003e4-6\u003c/sup\u003e.\u0026nbsp;We estimated that about 10% of cases remain genetically unsolved in our French cohort of autosomal dominant RP cases. Recent advancements in sequencing technologies and bioinformatic tools combined with candidate gene approaches and functional studies are aiming at solving the missing gene defects. Thus, the aim of the study herein was to identify the missing gene defects in genetically unsolved autosomal dominant or sporadic cases with RP using genome and direct Sanger sequencing, combined with a candidate gene approach.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eIdentification of\u003cem\u003e\u0026nbsp;RNU4-2\u003c/em\u003e, \u003cem\u003eRNU6-1\u003c/em\u003e, \u003cem\u003eRNU6-2, RNU6-8\u003c/em\u003e and \u003cem\u003eRNU6-9\u003c/em\u003e variants in a French cohort with autosomal dominant RP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy performing genome sequencing (GS) in 4 genetically unsolved autosomal dominant RP families, applying filtering based on the allele frequency, in silico prediction programs, and segregation in the sequenced family members\u0026nbsp;(see Methods), still ~15,000-43,000 heterozygous candidate disease causing variants remained. Subsequently, variants identified in genes being previously (Table 1) and more recently associated (Table 2) with RP were investigated in more details.\u003csup\u003e26\u003c/sup\u003e Using this prioritization method, we identified the following variants in the snRNA genes: the n.55_56insG (F581) and the n.56_57insG (F1545) in \u003cem\u003eRNU6-1,\u0026nbsp;\u003c/em\u003ethe n.55_56insG (F4754) in\u003cem\u003e\u0026nbsp;RNU6-8\u0026nbsp;\u003c/em\u003eand the n.56T\u0026gt;C (F6788) in \u003cem\u003eRNU4-2\u0026nbsp;\u003c/em\u003e(Table 2). Although different variants in \u003cem\u003eRNU1\u003c/em\u003e, \u003cem\u003eRNU2\u003c/em\u003e, \u003cem\u003eRNU4\u003c/em\u003e, \u003cem\u003eRNU5\u003c/em\u003e and \u003cem\u003eRNU6\u003c/em\u003e (Supplementary table 1) paralogs were identified in other unsolved families, they were not considered to be pathogenic due to their high frequency in gnomAD v3.1.2, e.g. in one remaining unsolved adRP family 260 variants were annotated in all snRNA paralogs but none had an allele frequency ≤0.005.\u003c/p\u003e\n\u003cp\u003eFor family F581, GS was performed in the affected women, CIC00914 and her affected daughter, CIC13399. More than 16,400 heterozygous variants were identified co-segregating with the phenotype in both affected cases. One of the putative candidate variants was located in\u0026nbsp;\u003cem\u003eSNRPN\u003c/em\u003e, a gene associated with Prader-Willi Syndrome, which was however not considered to be pathogenic due to its high prevalence in the general population and inconsistency with the RP phenotype (Tables 1 and 3). Subsequently, the candidate gene\u003csup\u003e26\u003c/sup\u003e approach identified the n.55_56insG variant in \u003cem\u003eRNU6-1,\u0026nbsp;\u003c/em\u003eco-segregating with the phenotype in available family members (Table 2, Figure 1)\u003c/p\u003e\n\u003cp\u003eFor Family F1545, GS was performed in the affected women, CIC03564 and her asymptomatic sister, CIC10996. More than 43,550 heterozygous variants were identified, co-segregating with the assumed phenotype of this family. One of the putative candidate variants was located in\u0026nbsp;\u003cem\u003eCCR5\u003c/em\u003e, a gene not expressed in the retina and associated with phenotypes such as diabetes mellitus, insulin-dependent, resistance to hepatitis C virus, susceptibility/resistance to human immunodeficiency virus infection, and susceptibility to West Nile virus, not explaining the RP phenotype of our index subject (Tables 1 and 3). Subsequently, the candidate gene\u003csup\u003e26\u003c/sup\u003e approach identified the n.56_57insG variant in \u003cem\u003eRNU6-1\u0026nbsp;\u003c/em\u003ein the index and asymptomatic sister (Table 2, Figure 1).\u003c/p\u003e\n\u003cp\u003eFor Family F4754, GS was performed in the affected male, CIC08435 and his affected brother, CIC10249. More than 13,100 heterozygous variants were identified. One of the putative candidate variants was located in \u003cem\u003eSNRNP200\u003c/em\u003e, an excellent candidate gene, implicated in adRP\u003csup\u003e15\u003c/sup\u003e, which was however absent in the affected brother, and thus excluded as disease-causing in this family. Subsequently, the candidate gene\u003csup\u003e26\u003c/sup\u003e approach identified the n.55_56insG variant in \u003cem\u003eRNU6-8\u0026nbsp;\u003c/em\u003ein the index and affected brother (Table 2, Figure 1).\u003c/p\u003e\n\u003cp\u003eFor Family F6788 GS was performed in the affected women, CIC11764 and her affected mother, CIC11765. More than 15,533 heterozygous variants were identified, co-segregating with the assumed phenotype of this family. Two putative candidate variants were identified, one heterozygous variant in \u003cem\u003eCEP290\u003c/em\u003e\u003cem\u003e\u003csup\u003e29\u003c/sup\u003e\u003c/em\u003e and one heterozygous variant in\u003cem\u003e\u0026nbsp;NMNAT1\u003c/em\u003e\u003csup\u003e30\u003c/sup\u003e, both of which are well-established genes implicated in IRDs, but known to follow an autosomal recessive mode of inheritance. Since this mode of inheritance was not consistent with that observed in Family F6788 (Figure 1), and no second heterozygous variant in trans was detected in both genes, these variants were excluded as disease-causing in this family. Subsequently, the candidate gene\u003csup\u003e26\u003c/sup\u003e approach identified the NR_003137.2 n.56T\u0026gt;C variant in \u003cem\u003eRNU4-2\u0026nbsp;\u003c/em\u003ein the index and affected mother (Table 2, Figure 1).\u003c/p\u003e\n\u003cp\u003eSubsequent Sanger sequencing of an unsolved RP cohort taking into account all RP-associated snRNA genes, genetically solved 4 further families with autosomal dominant RR (Figure 1) harboring heterozygous variants in the snRNA genes: the n.55_56insG (F1111) in\u0026nbsp;\u003cem\u003eRNU6-9\u003c/em\u003e, the n.55_56insG (F4368) in\u0026nbsp;\u003cem\u003eRNU6-2\u0026nbsp;\u003c/em\u003eand the n.18_19insA (F5387 and F6085) in\u0026nbsp;\u003cem\u003eRNU4-2\u003c/em\u003e (Fig.1).\u003c/p\u003e\n\u003cp\u003eThese variants co-segregated with the phenotype following an autosomal dominant mode of inheritance (Fig. 1). All variants were absent from the general population (Genome Aggregation Database v4.1.0 database) and predicted to be pathogenic using the annotation of the American College of Medical Genetics and Genomics guidelines (Table 2)\u003csup\u003e31\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRNU4-2\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-1\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-2, RNU6-8\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-9\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;variants are predicted to alter the binding of the U4/U6 duplex with the splicing factors PRPF3, PRPF6, PRPF8 and PRPF31\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;\u003cem\u003eRNU4-2\u003c/em\u003e variant n.18_19insA inserts a nucleotide in the loop created at the junction of the stem I, stem II and 5’ stem loop and also the n.56T\u0026gt;C variant is localized in this same loop. As previously performed,\u0026nbsp;\u003cem\u003ein silico\u003c/em\u003e modeling predicted that both variants will extend the size of the junction and alter the orientation of the stems\u003csup\u003e26\u003c/sup\u003e. These structural changes are predicted to compromise the overall stability of the U4/U6 duplex \u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;\u003cem\u003eRNU6\u003c/em\u003e paralogous variants n.55_56insG and n.56_57insG insert a nucleotide in the stem I. Both variants are predicted to extend the stem I by pairing three additional nucleotides. As previously shown the extension of stem I significantly reduces the size of the junction and alters the orientation of the stems\u003csup\u003e26\u003c/sup\u003e. These changes in the secondary structure are predicted to disrupt the correct binding of the U4/U6 duplex\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eInterestingly, the variants identified herein are located in regions of U4 and U6 interacting with PRPF3 and PRPF31 via hydrogen bonds (Fig. 2). Subsequently, other factors will bind to stabilize the complex. Thus, the identified variants in \u003cem\u003eRNU4-2\u003c/em\u003e and \u003cem\u003eRNU6\u003c/em\u003e paralogs will disrupt the overall assembly of the U4/U6.U5 tri-snRNP and then seriously impact the function of the entire splicing complex (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients with variants in\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;RNU4-2\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-1\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-2,\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-8\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-9\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;reveal adRP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 reports clinical findings in probands and available family members carrying variants in\u0026nbsp;\u003cem\u003eRNU4-2\u0026nbsp;\u003c/em\u003eor\u0026nbsp;\u003cem\u003eRNU6\u0026nbsp;\u003c/em\u003eparalogs identified in this study. Family pedigrees are displayed in Fig. 1 and multimodal retinal imaging of the right eyes presented in Fig. 3. All families were from French descent beside one (F6085) originating from Madeira. Proband cases all reported family history suggesting adRP. For one pedigree (F1545), one sister of proband (CIC10996) carried the likely pathogenic variant in\u0026nbsp;\u003cem\u003eRNU6-1\u003c/em\u003e but was said to be asymptomatic but was not available for proper examination. In addition, one proband (CIC11764) had more advanced disease than her mother (CIC11765) only mildly affected at the time of her daughter’s diagnosis suggesting a variable expressivity in this case. Besides, 2/8 subjects with a history of thyroid inflammatory disease and on case with pseudotumor of one eye, none had specific systemic conditions. Age at time of diagnosis was available for 5/8 probands with mean age being 20.6±6.95. Night vision disturbances were the first symptom reported by all probands with at least half of the cases with childhood onset. Age at time of examination was 47.4±14.6. Mean best corrected visual acuity was 0.33 LogMar on the right and 0.31 on the left. There was no consistent refractive error across cases. The Lanthony 15-desaturated hue color vision test had been performed in 5/8 probands and showed a tritan defect for 3/5. All subjects aged 50 or more had a reduced visual field at the binocular III4e to the 20 central degrees. All subjects within their fifties either had posterior subcapsular cataract or had undergone cataract surgery. Fundus examination showed a distinct marked chorioretinal atrophy including the peripapillary area with pale disc and narrowed retinal vessels in 5/8 cases with multimodal imaging in keeping with relative central macula preservation (Fig. 3). In addition, 5/8 cases and 1 sibling had a history of cystoid maculopathy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur work described herein genetically solved 2% families with autosomal dominant RP harboring variants in the U4 and U6 small noncoding nuclear RNA by a combination of GS, candidate gene\u003csup\u003e26\u003c/sup\u003e and Sanger sequencing approaches. Variants in these RNA genes were most likely missed before since gene defect identification largely focused on protein coding genes. However, splicing has been shown to play a crucial role for the proper functioning of the retina\u003csup\u003e32\u003c/sup\u003e and thus components important for the splicing machinery represent excellent candidate genes to be implicated in retina pathology. Indeed, nearly all human genes contain introns, which are excised during pre-mRNA splicing as part of post-transcriptional processing\u003csup\u003e33\u003c/sup\u003e. Small noncoding nuclear RNAs (U1, U2, U4, U5, and U6) and several associated proteins, such as PRPF31, PRPF8, PRPF3, SNRNP200 and PRPF6, known to be associated with autosomal dominant RP, belong to the spliceosome multisubunit complex catalyzing this reaction\u003csup\u003e34\u003c/sup\u003e. These findings support the variants in \u003cem\u003eRNU4\u003c/em\u003e and \u003cem\u003eRNU6\u003c/em\u003e paralogs identified herein and by Ouinodoz et al.\u003csup\u003e26\u003c/sup\u003e as strong candidate for disease-causing variants underlying autosomal dominant RP. All cases carrying these variants in our study recognized a family history of autosomal dominant RP with one occurrence of possible incomplete penetrance and one with variable expressivity. Clinical characteristics include onset of symptoms in early childhood for most cases and retinal alterations consistent with the diagnosis of RP with a predominance of chorioretinal atrophy and cystoid maculopathy.\u003c/p\u003e\n\u003cp\u003eInterestingly, several very recent studies highlighted heterozygous disease-causing variants in these RNA genes, such as \u003cem\u003eRNU4-2\u003c/em\u003e but also \u003cem\u003eRNU2-2,\u003c/em\u003e \u003cem\u003eRNU5B-1\u003c/em\u003e and \u003cem\u003eRNU5A-1\u003c/em\u003e, in severe neurodevelopmental disorders (NDD) \u003csup\u003e35-44\u003c/sup\u003e. None of these features were present in our patients with autosomal dominant RP. In the majority of cases with NDD the variants occurred \u003cem\u003ede novo\u003c/em\u003e (e.g.\u003csup\u003e37\u003c/sup\u003e). Interestingly, although DNA for genetic testing was not available from all family members of our RP cohort, the family pedigrees clearly demonstrated that the variants were inherited in an \u0026nbsp;autosomal dominant manner (Fig. 1). Indeed, all variants co-segregated with an \u0026nbsp;autosomal dominant mode of inheritance in all family members available for genetic testing (e.g. Fig. 1, F6788, F581), except in one (Fig. 1, F1545, CIC10966). In the latter one, the index subject CIC03564 of family F1545 had typical RP with night blindness since childhood, while her older sister, CIC10996 was reported to be asymptomatic and was aged 80 at last report, although not available to us for ophthalmic assessment, suggesting incomplete penetrance, a finding also reported with splicing factors such as \u003cem\u003ePRPF31\u003c/em\u003e.\u003csup\u003e9\u003c/sup\u003e Furthermore, in F6788, proband CIC11764 showed more advanced disease than her mother suggesting variable expressivity. Remarkably, pedigree analysis revealed that 27 subjects were females out of the 39 affected cases in our 8 RP families. This was especially striking in F5387 (Fig. 1), where only 1 male out of 8 females was affected. Similarly, in individuals with NDD carrying a genetic variant in \u003cem\u003eRNU4-2\u003c/em\u003e, the variant was consistently found on the maternal allele.\u003csup\u003e38\u003c/sup\u003e This pattern may reflect negative selection in the male germline if \u003cem\u003eRNU4-2\u003c/em\u003e and \u003cem\u003eRNU6\u003c/em\u003e paralogs are critical for spermatogenesis. Alternatively, it could result from imprinting, whereby variants on a highly expressed paternal allele lead to embryonic lethality, while those on a less active maternal allele are compatible with survival but result in NDD.\u003csup\u003e38\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur findings are distinct from the study by Quinodoz et al.,\u003csup\u003e26,45\u003c/sup\u003e There,\u0026nbsp;\u003cem\u003eRNU4-2\u003c/em\u003e and \u003cem\u003eRNU6\u003c/em\u003e variants were frequently reported as \u003cem\u003ede novo\u003c/em\u003e with incomplete penetrance leading to RP. There was also no sex-specific negative selection during gametogenesis or at the embryonic state.\u003csup\u003e26,45\u003c/sup\u003e A more precise clinical investigations of all family members of our and the families reported in the study by Quinodoz et al.,\u003csup\u003e26\u003c/sup\u003e may shed light on these observed differences in patients with RP.\u003c/p\u003e\n\u003cp\u003eOf importance, variants in the RNA genes leading to autosomal dominant RP cluster in distinct regions as variants leading to neurodevelopmental disorders (Fig. 4). Autosomal dominant RP-variants affecting U4 and U6 are located close to the three-way junction, a site that is crucial for the U4/U6.U5 tri-snRNP complex assembly with PRPF3, PRPF8 and PRPF31 (Figs. 2 and 4). On the other side, variants reported in patients with neurodevelopmental disorders affect the stem III and T-loop, which position the U6 ACAGAGA box at the 5’splice site recognition which may have distinct functional consequences leading to a distinct phenotype\u003csup\u003e37\u003c/sup\u003e. Due to the interaction of U5 with the tri-snRNP complex, \u003cem\u003eRNU-5\u003c/em\u003e reflects also a good candidate to be mutated in cases with RP. However, none of our GS and genetically unsolved families with RP, harbored predicted disease-causing variants in these RNA paralogs. Further GS needs to be applied to all unsolved cases with RP and sequencing data analyzed not only focusing on protein coding genes.\u003c/p\u003e\n\u003cp\u003eOur findings helped to genetically solve 8 additional families of\u0026nbsp;our French cohort of 395\u0026nbsp;autosomal dominant RP families. As found in other studies, in our cohort variants in \u003cem\u003eRHO\u003c/em\u003e (102 cases)\u003csup\u003e46\u003c/sup\u003e represents the major gene defect underlying a autosomal dominant RP, followed by \u003cem\u003ePRPH2\u003c/em\u003e (59)\u003csup\u003e47\u003c/sup\u003e, \u003cem\u003ePRPF31\u0026nbsp;\u003c/em\u003e(59 cases)\u003csup\u003e8\u003c/sup\u003eand \u003cem\u003eRP1\u0026nbsp;\u003c/em\u003e(48 cases)\u003csup\u003e10\u003c/sup\u003e (Fig. 5). Besides the relatively high prevalence of disease-causing variants in the pre-mRNA splicing factor \u003cem\u003ePRPF31\u003c/em\u003e, we identified in our cohort 23, 20 and 13 autosomal dominant RP families with disease-causing variants in \u003cem\u003ePRPF8\u003c/em\u003e, \u003cem\u003ePRPF3\u003c/em\u003e, \u003cem\u003eSNRNP200\u003c/em\u003e respectively and 5 possible disease-causing variants in \u003cem\u003ePRPF6\u003c/em\u003e. Together, adding the findings presented herein, variants in \u003cem\u003eRNU4-2\u003c/em\u003e and \u003cem\u003eRNU6\u0026nbsp;\u003c/em\u003eparalogs account for 2% of our solved cases with\u0026nbsp;autosomal dominant RP and variants in genes important for the spliceosome multisubunit complex represents 6% of all\u0026nbsp;autosomal dominant RP cases (Figure 5). These findings along with those of Quinodoz\u0026nbsp;et al.,\u003csup\u003e26\u003c/sup\u003e outline the importance of major components of the multisubunit spliceosome complex including\u0026nbsp;small noncoding nuclear RNAs for photoreceptor homeostasis. The reason why spliceosome defects such as those discussed in the present work, lead to a retina-restricted phenotype, namely a rod-cone dystrophy, although pre-mRNA splicing is a ubiquitous phenomenon, is still a matter of debate. The retina is associated with high splicing demand and expresses very high levels of spliceosomal snRNAs and processes more pre-mRNA than other tissues\u003csup\u003e48\u003c/sup\u003e. Considering the high metabolic activity and protein turnover in photoreceptors, even a mild reduction in splicing efficiency would disproportionately affects retinal cells. In addition, previous works have suggested a selective vulnerability of retinal transcripts to mis-splicing in case of spliceosome defects, while global splicing may be preserved\u003csup\u003e49\u003c/sup\u003e. Furthermore, many genes expressed in photoreceptor may rely on alternative splicing to generate retina-specific isoforms. Several studies have documented the mis-splicing profile associated with PRPFs pathogenic variants with a widespread effect on phototransduction, ciliary proteins and RNA processing\u003csup\u003e50-52\u003c/sup\u003e. Similarly, studies on retinal organoids and retinal pigment epithelial cells derived from patients carrying snRNA gene defects may shed further light in their pathogenic mechanisms and may help design therapeutic interventions.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants and clinical assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were identified from a large historical cohort of individuals affected with RP who underwent comprehensive ophthalmic examinations, including standard-of-care retinal imaging and functional assessments as previously described\u003csup\u003e53\u003c/sup\u003e. All participants had long remained genetically unsolved and underwent genome sequencing (GS), exome sequencing (ES), or targeted candidate gene screening. All 7 probands were identified at the National Refence Centre for rare retinal diseases REFERET of Quinze-Vingts Hospital (Paris, France) within a cohort of autosomal dominant RP patients. The study protocol adhered to the tenets of the Declaration of Helsinki and received approval from the local ethics committees (Committees of Protection of Persons Ile de France V, Project number 06693, N◦EUDRACT 2006-A00347-44, 11 December 2006). Written, informed consent was obtained from all participants prior to their inclusion in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGenetic analyses, variant prioritization, and in silico prediction tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBlood samples were obtained from probands, and when possible, other family members. Total genomic DNA was extracted from peripheral blood lymphocytes by standard procedures as performed before.\u003csup\u003e53\u003c/sup\u003e GS was performed on 4 families (Fam581, Fam1545, Fam4754 and Fam6788) (Integragen, Evry, France) using a NovaSeq600 instrument, as previously described.\u003csup\u003e\u0026nbsp;28\u003c/sup\u003e The sequencing data processing was done as previously described.\u003csup\u003e5\u003c/sup\u003e Briefly, we used bwa 0.7.17 (https://doi.org/10.1093/bioinformatics/btp324) for the mapping onto the hg38 reference genome, \u0026nbsp; GATK 4.1.7.0 \u003csup\u003e54\u003c/sup\u003e for variant calling step and ANNOVAR\u0026nbsp;\u003csup\u003e55\u003c/sup\u003e for variant annotation. The annotation includes scores from many \u003cem\u003ein-silico\u003c/em\u003e prediction programs such as CADD\u0026nbsp;\u003csup\u003e56\u003c/sup\u003e, AlphaMissense\u0026nbsp;\u003csup\u003e57\u003c/sup\u003e, REVEL\u0026nbsp;\u003csup\u003e58\u003c/sup\u003e,\u0026nbsp;BayesDel\u0026nbsp;\u003csup\u003e59\u003c/sup\u003e, and MetaRNN\u0026nbsp;\u003csup\u003e60\u003c/sup\u003e, SpliceAI\u0026nbsp;\u003csup\u003e61\u003c/sup\u003e, Pangolin.\u0026nbsp;\u003csup\u003e62\u003c/sup\u003e Variants with a minor allele frequency\u0026nbsp;\u0026le;\u0026nbsp;0.005 in the Genome Aggregation Database v3.1.2 (https://gnomad.broadinstitute.org) were prioritized if they were classified as pathogenic, likely pathogenic, or of uncertain significance according to the American College of Medical Genetics and Genomics (ACMG) guidelines\u003csup\u003e31\u003c/sup\u003e, and if they were heterozygous and segregated within affected family members.\u0026nbsp;In cases where variant prioritization based on allele frequency, predicted pathogenicity, and familial segregation did not yield credible candidates, a systematic review of recent literature was conducted. This bibliographic search specifically targeted genes newly associated with dominant retinal diseases in articles and preprints published within the last 24 months. Among the identified candidates, a key publication highlighted the involvement of two snRNAs in the spliceosome. Consequently, all spliceosomal snRNA genes were considered as candidates (supp table). These genes were subsequently analyzed to detect rare variants in our cohort. In all cases, direct Sanger sequencing was performed to validate the identified variants on the probands and perform segregation analysis on all available family members. Direct Sanger sequencing was also applied to screen our cohort of unsolved cases (~300 cases) for all \u003cem\u003eRNU4-1\u0026nbsp;\u003c/em\u003e(NR_003925.1), \u003cem\u003eRNU4-2\u0026nbsp;\u003c/em\u003e(NR_003137.2)\u003cem\u003e, RNU6-1\u0026nbsp;\u003c/em\u003e(NR_004394.1)\u003cem\u003e, RNU6-2\u003c/em\u003e (NR_125730.1)\u003cem\u003e, RNU6-7\u0026nbsp;\u003c/em\u003e(NR_104084.1)\u003cem\u003e, RNU6-8\u0026nbsp;\u003c/em\u003e(NR_104088.1)and \u003cem\u003eRNU6-9\u003c/em\u003e (NR_104080.1)genes. Details regarding primers and PCR and Sanger sequencing conditions will be available on request. We used RNAfold WebServer\u0026nbsp;\u003csup\u003e63\u003c/sup\u003e with default parameters to predict the impact of variants in the U4/U6 secondary structure and RNAcanvas v1.1.16\u0026nbsp;\u003csup\u003e64\u003c/sup\u003e to draw it. We loaded the human U4/U6.U5 tri-snRNP\u0026nbsp;\u003csup\u003e65\u003c/sup\u003e PDB file into PyMOL 2.5 for 3D modeling.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and materials will be supplied upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are thankful to the patient and family members participating in the study and clinical staff from the Reference Center for rare diseases REFERET at Quinze-Vingts Hospital. DNA samples included in this study originate from NeuroSensCol DNA bank (PI: I Audo, partner with Centre Hospitalier National d\u0026rsquo;Ophtalmologie des Quinze-Vingts, INSERM and CNRS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by Fondation Voir et Entendre (C.Z.), by French state funds managed by the Agence Nationale de la Recherche within the Investissements d\u0026rsquo;Avenir program (ANR-11-IDEX-0004-0), IHU FOReSIGHT (ANR-18-IAHU-0001 to I.A. and C.Z.) and ANR-23-CE17-0014-01 RP_SOLVEANDCURE to C.Z. and I.A.), LABEX LIFESENSES (ANR-10-LABX-65 to I.A. and C.Z.) and Retina France (I.A. and C.Z. ), Foundation Fighting Blindness center grant (C-CMM-0907-0428-INSERM04 to I.A. and C.Z.), grant (BR-GE-0619-0761-INSERM to I.A. and C.Z.), UNADEV (Union Nationale des Aveugles et Deficient Visuels to I.A. and C.Z.) in partnership with ITMO NNP/AVIESAN (alliance nationale pour les sciences de la vie et de la sant\u0026eacute;) for research in visual disorders and the Fondation de l\u0026rsquo;oeil (Prix de la Fondation de l\u0026rsquo;oeil I.A. and C.Z.).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: J.N., I.A., C.Z.; Writing-original draft: J.N., I.A., C.Z.; Writing-review \u0026amp; editing: J.N., I.A., C.Z.; Data curation: J.N., L.B., A.Antro., C.C., A.Anto., C.A., S.M.-S., C.L.-C., R.A., A.B., V.S., J.S. I.M. Formal analysis: L.B., J.N., C.C., A.Anto., A.Antro., C.A., E.M.P., E.A.P., S.E.S., V.S., V.K., L.M., A.R., B.B., J-A.S.. . Supervision: C.Z., I.A; Funding acquisition: C.Z., I.A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll institutions involved in human participant research received national or local IRB approval (Committees of Protection of Persons Ile de France V, Project number 06693, N◦EUDRACT 2006-A00347-44, 11 December 2006). Written informed consent was obtained from all individuals. All studies were carried out in accordance with the declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing financial interest in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBerger W, Kloeckener-Gruissem B, Neidhardt J. 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Am J Hum Genet. 2006;79:556\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalk MJ, et al. NMNAT1 mutations cause Leber congenital amaurosis. Nat Genet. 2012;44:1040\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichards S, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015;17:405\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu MM, Zack DJ. Alternative splicing and retinal degeneration. Clin Genet. 2013;84:142\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey FE, et al. Clinical interpretation and implications of whole-genome sequencing. JAMA. 2014;311:1035\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWahl MC, Will CL, Luhrmann R. The spliceosome: design principles of a dynamic RNP machine. \u003cem\u003eCell\u003c/em\u003e 136, 701\u0026thinsp;\u0026ndash;\u0026thinsp;18 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreene D, et al. Mutations in the U4 snRNA gene RNU4-2 cause one of the most prevalent monogenic neurodevelopmental disorders. Nat Med. 2024;30:2165\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDanovi S. RNU4-2 variants cause neurodevelopmental disorders. Nat Genet. 2024;56:1541.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNava C et al. Dominant variants in major spliceosome U4 and U5 small nuclear RNA genes cause neurodevelopmental disorders through splicing disruption. Nat Genet (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, et al. De novo variants in the RNU4-2 snRNA cause a frequent neurodevelopmental syndrome. Nature. 2024;632:832\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackson A, et al. Analysis of R-loop forming regions identifies RNU2-2 and RNU5B-1 as neurodevelopmental disorder genes. Nat Genet. 2025;57:1362\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuroda Y et al. Genotype-phenotype correlations and phenotypic expansion in a case series of ReNU syndrome associated with RNU4-2 variants. J Med Genet (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamoto N et al. A Clinical Study of Nine Patients With ReNU Syndrome. Am J Med Genet A, e64151 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenblum J, et al. RNU4-2-Related Neurodevelopmental Disorder Is Associated With a Recognisable Facial Gestalt. Clin Genet. 2025;107:104\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchot R, Ferraro F, Geeven G, Diderich KEM, Barakat TS. Re-analysis of whole genome sequencing ends a diagnostic odyssey: Case report of an RNU4-2 related neurodevelopmental disorder. Clin Genet. 2024;106:512\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNegi S, et al. Advancing long-read nanopore genome assembly and accurate variant calling for rare disease detection. Am J Hum Genet. 2025;112:428\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinodoz M et al. De novo and inherited dominant variants in U4 and U6 snRNAs cause retinitis pigmentosa. \u003cem\u003emedRxiv\u003c/em\u003e (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAudo I, et al. Spectrum of rhodopsin mutations in French autosomal dominant rod-cone dystrophy patients. Invest Ophthalmol Vis Sci. 2010;51:3687\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManes G, et al. High prevalence of PRPH2 in autosomal dominant retinitis pigmentosa in france and characterization of biochemical and clinical features. Am J Ophthalmol. 2015;159:302\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanackovic G, et al. PRPF mutations are associated with generalized defects in spliceosome formation and pre-mRNA splicing in patients with retinitis pigmentosa. Hum Mol Genet. 2011;20:2116\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinder B, et al. Systemic splicing factor deficiency causes tissue-specific defects: a zebrafish model for retinitis pigmentosa. Hum Mol Genet. 2011;20:368\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorir PK, Roberts L, Ramesar R, Seoighe C. A mutation in a splicing factor that causes retinitis pigmentosa has a transcriptome-wide effect on mRNA splicing. BMC Res Notes. 2014;7:401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzizzadeh Pormehr L, Ahmadian S, Daftarian N, Mousavi SA, Shafiezadeh M. PRPF31 reduction causes mis-splicing of the phototransduction genes in human organotypic retinal culture. Eur J Hum Genet. 2020;28:491\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodrigues A, et al. Modeling PRPF31 retinitis pigmentosa using retinal pigment epithelium and organoids combined with gene augmentation rescue. Ocul Immunol Inflamm. 2022;7:39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAudo I, et al. An unusual retinal phenotype associated with a novel mutation in RHO. Arch Ophthalmol. 2010;128:1036\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKenna A, et al. The Genome Analysis Toolkit: a MapReduce framework for analyzing next-generation DNA sequencing data. Genome Res. 2010;20:1297\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang K, Li M, Hakonarson H. ANNOVAR: functional annotation of genetic variants from high-throughput sequencing data. Nucleic Acids Res. 2010;38:e164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchubach M, Maass T, Nazaretyan L, Roner S, Kircher M. CADD v1.7: using protein language models, regulatory CNNs and other nucleotide-level scores to improve genome-wide variant predictions. Nucleic Acids Res. 2024;52:D1143\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTordai H, et al. Analysis of AlphaMissense data in different protein groups and structural context. Sci Data. 2024;11:495.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIoannidis NM, et al. REVEL: An Ensemble Method for Predicting the Pathogenicity of Rare Missense Variants. Am J Hum Genet. 2016;99:877\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian Y, et al. REVEL and BayesDel outperform other in silico meta-predictors for clinical variant classification. Sci Rep. 2019;9:12752.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Zhi D, Wang K, Liu X. MetaRNN: differentiating rare pathogenic and rare benign missense SNVs and InDels using deep learning. Genome Med. 2022;14:115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaganathan K, et al. Predicting Splicing from Primary Sequence with Deep Learning. Cell. 2019;176:535\u0026ndash;e54824.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng T, Li YI. Predicting RNA splicing from DNA sequence using Pangolin. Genome Biol. 2022;23:103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGruber AR, Lorenz R, Bernhart SH, Neubock R, Hofacker IL. The Vienna RNA websuite. Nucleic Acids Res. 2008;36:W70\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson PZ, Simon AE. RNAcanvas: interactive drawing and exploration of nucleic acid structures. Nucleic Acids Res. 2023;51:W501\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharenton C, Wilkinson ME, Nagai K. Mechanism of 5' splice site transfer for human spliceosome activation. Science. 2019;364:362\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Primary candidate variants identified by genome sequencing and reasoning why they were discarded\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"954\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of variants*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBest candidate genes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTranscript\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHGVS c.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHGVS .p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZygosity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACMG Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACMG Classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egnomAD v3.1.2 allele frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egnomAD v3.1.2 allele count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscarded reason\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF581\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC00914 affected female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e16464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eSNRPN\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(MIM:\u003cem\u003e\u0026nbsp;\u003c/em\u003e182279)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNM_001378251.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003echr15:24886591T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003ec.-738+2T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003ep.(?)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003eVUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.11E-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eToo frequent in gnomAD v3.1.2 gene associated with Prader-Willi syndrome (MIM:176270) and Angelman syndrome (MIM: 105830 not compatible with RP phenotype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC11339\u003c/p\u003e\n \u003cp\u003eaffected daughter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF1545\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC03564 affected female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e43552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eCCR5\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(MIM: 601373)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eNM_001394783.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003echr3:46373205A\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ec.303T\u0026gt;A\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003ep.(Cys101*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ePM2, BS2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eVUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8.475E-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e129, 6 ho\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eGene not expressed in retina; gene associated Diabetes mellitus, insulin-dependent (MIM:612522), Hepatitis C virus, resistance to (MIM: 609532), HIV infection, susceptibility/resistance to (MIM: 609423) and West Nile virus, susceptibility to (MIM: 610379), \u0026nbsp; \u0026nbsp;not compatible with RP phenotype\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC10996\u003c/p\u003e\n \u003cp\u003eAsymptomatic sister\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eho ref\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF4754\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC08435 affected male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e13107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eSNRNP200\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(MIM: 601664)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNM_014014.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003echr2:96292971C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003ec.2160+1G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003ep.(?)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ePM2, PVS1, BS4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eVUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAbsent in affected brother\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC10249 affected brother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eHo ref\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF6788\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC11764 affected female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eCEP290\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(MIM: 610142)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNM_025114.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003echr12:88055700A\u0026gt;T\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003ec.6836T\u0026gt;A\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003ep.(Leu2279*)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePVS1, PM2, PP5, PS3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAbsence of second variant in trans; gene is not associated with autosomal dominant mode of inheritance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC11765 affected mother\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eHet\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC11764 affected female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eNMNAT1\u003c/em\u003e (MIM: 608700)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNM_022787.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003echr1:9982630G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003ec.769G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003ep.(Glu257Lys)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003ehet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePS4, PM2, PP2, PP3, PP5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8.149E-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAbsence of second variant in trans; gene is not associated with autosomal dominant mode of inheritance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCIC11765 affected mother\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eHet\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Relative low allele frequency in gnomAD v3.1.2, and/or pathogenic, likely pathogenic or variant of uncertain significance (VUS) according to ACMG (American college of Medical Genetics and Genomics) classification, heterozygous for the affected sequenced samples. het: heterozygous. ho ref: homozygous for the reference sequence. HGSV: Human Genome Variation Society. c.: coding sequence. p.: protein position. n.a.: not applicable. PVS1: pathogenic very strong. PS3: pathogenic strong (functional assays). PS4: pathogenic strong (frequently present in affected cases compared to control). PM2: pathogenic moderate (rare in gnomAD v3.1.2). PP2: pathogenic supporting (low tolerance for benign variants). PP3: pathogenic supporting (reported in clinical databases e.g. ClinVar). BS2: benign strong (reported in healthy adults). BS: benign strong (does not co-segregate with the phenotype in the family).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Pathogenic variants in\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU4-2\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-1\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-2, RNU6-8\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6-9\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;leading to RP\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"784\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariant ID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eVariant Description\u0026nbsp;GRCh38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGene\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTranscript\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of families\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAllele count gnomAD v3.1.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACMG Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACMG classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000012.12:g.120291885_120291886insT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU4-2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_003137.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.18_19insA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000012.12:g.120291848A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU4-2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_003137.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.56T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000015.10:g.67839990_67839991insC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU6-1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_004394.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.55_56insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000015.10:g.67839989_67839990insC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU6-1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_004394.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.56_57insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000019.10:g.1021576_1021577insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU6-2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_125730.1 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.55_56insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000014.9:g.32203214_32203215insC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU6-8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_104088.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.55_56insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eV7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eNC_000019.10:g.893538_893539insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNU6-9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNR_104080.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en.55_56insG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ePS3, PS4, PM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003epathogenic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAMCG, American college of Medical Genetics and Genomics; V: variant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Clinical findings in patients carrying variants in\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU4-2\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;or\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRNU6\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;paralogs\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1078\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eSubject #\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFamily #\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eancestry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eOphthalmic history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eAge at time of diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eAge at time of examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003cp\u003eRE/LE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003erefraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eKinetic visual field III4e\u003c/p\u003e\n \u003cp\u003eHxV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eColor vision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003eFundus examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eFAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eSD-OCT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC00914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eBilateral cataract surgery at 41 with capsulotomy 10 years later\u003c/p\u003e\n \u003cp\u003eBilateral cystoid maculopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eChildhood onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/125\u003c/p\u003e\n \u003cp\u003e20/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.50(-0.75)120\u0026deg;\u003c/p\u003e\n \u003cp\u003e-1.25(-1)105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u0026deg;x20\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral and peripapillary chorioretinal atrophy with coarse pigment migration\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePatchy loss of AF in the periphery and in the peripapillary area; increased AF at the central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL at the central macula with irregular EZ and loss of the IZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC01811\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF1111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eBilateral cataract surgery at 37 and 38\u003c/p\u003e\n \u003cp\u003eCapsulotomy 10 years later\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eEarly childhood onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/160\u003c/p\u003e\n \u003cp\u003e20/250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e+1.25(-0.50)90\u0026deg;\u003c/p\u003e\n \u003cp\u003e-0.25(-0.75)135\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u0026deg;x15\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eTritan defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral and peripapillary chorioretinal atrophy with coarse pigment migration Pale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003cp\u003ePerimacular vitreous traction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eWell demarcated loss of AF in the periphery including the peripapillary area; increased AF at the macula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL at the central macula with irregular EZ and loss of the IZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC03564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF1545\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eHigh blood pressure\u003c/p\u003e\n \u003cp\u003eThyroiditis leading to hypothyroidy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003ePseudo tumor of the RE at 56\u003c/p\u003e\n \u003cp\u003eBilateral cataract surgery at 59\u003c/p\u003e\n \u003cp\u003eCapsulotomy 5 years later\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003echildhood onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/40\u003c/p\u003e\n \u003cp\u003e20/80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e-3.5(-0.5)75\u0026deg;\u003c/p\u003e\n \u003cp\u003e-2.5(-0.75)120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u0026deg;x15\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eTritan defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral and peripapillary chorioretinal atrophy with coarse pigment migration and perifoveal atrophy\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLarge patchy loss of AF in the periphery including the peripapillary area; perifoveal loss of AF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eThinning of the ONL, disorganized EZ, loss of IZ, intraretinal cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC07828\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF4368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eBilateral cataract surgery at age 29\u003c/p\u003e\n \u003cp\u003eCapsulotomy 4 years later\u003c/p\u003e\n \u003cp\u003eBilateral cystoid maculopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eNight blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e+0.5(-0.50)10\u0026deg;\u003c/p\u003e\n \u003cp\u003e+0.75(-1.25)75\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u0026deg;x15\u0026deg; with bitemporal islands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral retinal changes with pigment migration\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLarge patchy loss of AF in the periphery with a perifoveal ring of increased AF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL and the hyper reflective bands at the central macula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC08435\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003eF4754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench, from Britany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCystoid maculopathy\u003c/p\u003e\n \u003cp\u003eSubcapsular and nuclear cataract BE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eNight blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/32\u003c/p\u003e\n \u003cp\u003e20/32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e-2.75\u003c/p\u003e\n \u003cp\u003e-2(-1.75)5\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u0026deg;x15\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNormal RE\u003c/p\u003e\n \u003cp\u003eTritan defect LE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral and peripapillary chorioretinal atrophy with subtle pigment migration and perifoveal atrophy\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLarge patchy loss of AF in the periphery including the peripapillary area; perifoveal loss of AF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL at the central macula with irregular EZ and loss of the IZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC10249, affected brother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCystoid maculopathy\u003c/p\u003e\n \u003cp\u003eSubcapsular and nuclear cataract BE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eNight blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/63\u003c/p\u003e\n \u003cp\u003e20/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e-2.25(-3)20\u0026deg;\u003c/p\u003e\n \u003cp\u003e-1.50(-3)160\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e25\u0026deg;x25\u0026deg; with a peripheral island on the left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral and peripapillary chorioretinal atrophy with subtle pigment migration and patch of macular atrophy RE\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLarge patchy loss of AF in the periphery including the peripapillary area; central loss of AF RE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL at the central macula with central loss of the hyper reflective bands RE et preservation with intraretinal cysts LE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC09384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF5387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNothing relevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eTeenage onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003ePlano\u003c/p\u003e\n \u003cp\u003ePlano\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e170\u0026deg;x20\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003eBeaten bronze appearance of the peripheral retina\u003c/p\u003e\n \u003cp\u003eSlightly pale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eSubtle changes in the periphery\u003c/p\u003e\n \u003cp\u003ePerifoveolar ring of increased fluorescence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePreservation of the ONL and the hyper reflective bands at the central macula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC10536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF6085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eFrom Madeira\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eHashimoto thyroiditis leading to hypothyroidy\u003c/p\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003cp\u003ePeritonitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCataract surgery at \u0026nbsp;50 and 55 YAG 2 years later BE\u003c/p\u003e\n \u003cp\u003eCystoid maculopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eChildhood onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/40\u003c/p\u003e\n \u003cp\u003e20/40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e+1.50(-1)100\u0026deg;\u003c/p\u003e\n \u003cp\u003e+0.75(-0.50)75\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u0026deg;x10\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ePeripheral retinal changes with pigment migration\u003c/p\u003e\n \u003cp\u003ePale optic disc and narrowed retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePatchy loss of AF in the periphery\u003c/p\u003e\n \u003cp\u003ePerifoveolar ring of increased fluorescence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eRelative preservation of the ONL and the hyper reflective bands at the central macula with intraretinal cysts BE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC11764\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003eF6788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003eFrench, Northern France\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eatopic dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCystoid maculopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eDecreased visual field superiorly and mild night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e+2.50(-1.50)25\u0026deg;\u003c/p\u003e\n \u003cp\u003e+2.50(-3)155\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e170\u0026deg;x100\u0026deg;\u003c/p\u003e\n \u003cp\u003eAltered superiorly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003eFew pigmentary changes in the periphery, normal optic disc and retinal vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePatchy loss of AF predominant in the inferior periphery and temporally\u003c/p\u003e\n \u003cp\u003eIncreased FA in the periphery of the posterior pole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePreservation of the ONL and the hyper reflective bands at the central macula with intraretinal cysts BE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eCIC11765, mother mildly affected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eKidney stones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eChildhood onset night blindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20/15\u003c/p\u003e\n \u003cp\u003e20/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e+2.75(-1)180\u003c/p\u003e\n \u003cp\u003e+3.50(-1.75)150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e170\u0026deg;x120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003enormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003eSubtle beaten bronze appearance in the periphery with very few pigments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eDiffuse subtle increased in AF in the periphery which appears granular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eThinning of the ONL in the periphery, very few drusenoid changes, preservation of the entire outer retinal bands in the periphery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBCVA: best corrected visual acuity; RE/LE: right eye/left eye; BE: both eye; HxV: horizontal by vertical; NA: not available; NP: not performed; FAF: fundus autofluorescence imaging; AF: autofluorescence; SD-OCT; spectral domain optical coherence tomography; ONL: outer nuclear layer; EZ: ellipsoid zone; IZ: interdigitation zone\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"genome-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Genome Medicine](https://genomemedicine.biomedcentral.com/)","snPcode":"13073","submissionUrl":"https://submission.springernature.com/new-submission/13073/3","title":"Genome Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9032551/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9032551/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Rod-cone dystrophy, also known as retinitis pigmentosa (RP), is a genetically heterogeneous group of retinal disorders with progressive rod then cone photoreceptor loss, leading to severe visual impairment. Autosomal dominant RP has been associated with about thirty genes, while approximately 10% of our French autosomal dominantRP cohort remain genetically unsolved. Recently, several variants in small nuclear RNA (snRNA) genes have been identified in cases with autosomal recessive and autosomal recessive neurodevelopmental disorders as well as autosomal dominant RP. These snRNAs undergo post-transcriptional modifications and, in association with proteins and other snRNAs, assemble into small nuclear ribonucleoproteins that are components of the spliceosome. By performing genome and direct Sanger sequencing, combined with a candidate gene approach, we identified heterozygous variants in RNU4-2 and RNU6 paralogs in eight unrelated non-syndromic autosomal dominant RP families, which co-segregated with the phenotype in available family members. RNU4-2 and RNU6 encode U4 and U6, snRNA, respectively, forming with U5, the tri-sn ribonucleoprotein (RNP) complex, representing the core of the major spliceosome. Interestingly, variants in autosomal dominant RP cases cluster in distinct locations than variants implicated in neurodevelopmental disorders, affecting regions important for tri-snRNP complex assembly with PRPF3, PRPF8 and PRPF31, also implicated in RP. Together, our findings revealed that 2% of our genetically solved cases with autosomal dominant RP carry variants in RNU4-2 or RNU6 paralogs. This represents 6% of all cases having variants in genes coding for the multisubunit complex, highlighting the importance of screening snRNA genes in cases of RP.","manuscriptTitle":"Variants in RNU4-2 or RNU6 paralogs account for 2% of cases with non-syndromic autosomal dominant retinitis pigmentosa in a large French","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-22 14:56:21","doi":"10.21203/rs.3.rs-9032551/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-03T06:46:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T14:53:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T17:04:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308343718977729435997215755597875551154","date":"2026-03-23T10:45:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297163250540992569383942950152319773029","date":"2026-03-18T05:26:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254037602853697765105425096577802831811","date":"2026-03-17T20:07:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T19:26:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-17T19:19:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-05T08:29:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Genome Medicine","date":"2026-03-04T16:44:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"genome-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Genome Medicine](https://genomemedicine.biomedcentral.com/)","snPcode":"13073","submissionUrl":"https://submission.springernature.com/new-submission/13073/3","title":"Genome Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da17a9be-b7b1-4244-9883-3e4dedbdece3","owner":[],"postedDate":"March 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-22T14:56:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-22 14:56:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9032551","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9032551","identity":"rs-9032551","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}