Neuro-Ophthalmology Panel

Neuro-ophthalmological disorders are a group of diseases that affect vision, control of eye movements, or pupillary reflexes. They include diseases restricted to the visual system and systemic diseases in which the neuro-ophthalmologic sign is accompanied by other neurological symptoms. Optic atrophy affects primarily the retinal ganglion cells and the nerve fiber layer of the retina leading to decreased visual acuity (see the description of the Optic Atrophy Panel for details). Congenital nystagmus is defined as conjugated, spontaneous and involuntary ocular oscillations that appear at birth or during the first three months of life. Binocular vision and color vision are normal and visual acuity is typically better than 6/12. Variants in the X-linked FRMD7 explain approximately 85% of patients with congenital nystagmus. Female mutation carriers can be affected. The prevalence of congenital nystagmus is estimated to be 1:3,000. Examples of syndromes associated with eye movement problems are ataxia with oculomotor apraxia type 1 and 2, caused by variants in APTX and SETX, respectively, and horizontal gaze palsy with progressive scoliosis caused by variants in ROBO3. Variants in TUBB3 are associated with an autosomal dominant strabismus syndrome called congenital fibrosis of the extraocular muscles. Mitochondrial diseases frequently manifest with neuro-ophthalmologic symptoms and signs. Progressive external ophthalmoplegia (PEO) is characterized by weakness of the eye muscles. The symptoms in PEO include drooping eyelids (ptosis) and weakness or paralysis of the muscles that move the eye (ophthalmoplegia), and in some cases skeletal muscle myopathy. Autosomal dominant PEO may be caused by variants in POLG, SLC25A4, or C10orf2. Ophthalmoplegia may also be associated with mitochondrial DNA depletion syndromes, which are a genetically and clinically heterogeneous group of autosomal recessive disorders.

The target region for each gene includes coding exons and ±20 base pairs from the exon-intron boundary. In addition, the panel includes non-coding and regulatory variants if listed above (Non-coding variants covered by the panel). Some regions of the gene(s) may be removed from the panel if specifically mentioned in the ‘Test limitations” section above. If the test includes the mitochondrial genome the target region gene list contains the mitochondrial genes. The sequencing data generated in our laboratory is analyzed with our proprietary data analysis and annotation pipeline, integrating state-of-the art algorithms and industry-standard software solutions. Incorporation of rigorous quality control steps throughout the workflow of the pipeline ensures the consistency, validity and accuracy of results. Our pipeline is streamlined to maximize sensitivity without sacrificing specificity. We have incorporated a number of reference population databases and mutation databases including, but not limited, to 1000 Genomes Project, gnomAD, ClinVar and HGMD into our clinical interpretation software to make the process effective and efficient. For missense variants, in silico variant prediction tools such as  SIFT, PolyPhen,MutationTaster are used to assist with variant classification. Through our online ordering and statement reporting system, Nucleus, ordering providers have access to the details of the analysis, including patient specific sequencing metrics, a gene level coverage plot and a list of regions with suboptimal coverage (<20X for nuclear genes and <1000X for mtDNA) if applicable. This reflects our mission to build fully transparent diagnostics where ordering providers can easily visualize the crucial details of the analysis process.

We provide customers with the most comprehensive clinical report available on the market. Clinical interpretation requires a fundamental understanding of clinical genetics and genetic principles. At Blueprint Genetics, our PhD molecular geneticists, medical geneticists, and clinical consultants prepare the clinical statement together by evaluating the identified variants in the context of the phenotypic information provided in the requisition form. Our goal is to provide clinically meaningful statements that are understandable for all medical professionals regardless of whether they have formal training in genetics.

Variant classification is the cornerstone of clinical interpretation and resulting patient management decisions. Our classifications follow the ACMG guideline 2015.

The final step in the analysis is orthogonal confirmation. Sequence and copy number variants classified as pathogenic, likely pathogenic, and variants of uncertain significance (VUS) are confirmed using bi-directional Sanger sequencing or by orthogonal methods such as qPCR/ddPCR when they do not meet our stringent NGS quality metrics for a true positive call.

Our clinical statement includes tables for sequencing and copy number variants that include basic variant information (genomic coordinates, HGVS nomenclature, zygosity, allele frequencies, in silico predictions, OMIM phenotypes, and classification of the variant). In addition, the statement includes detailed descriptions of the variant, gene, and phenotype(s) including the role of the specific gene in human disease, the mutation profile, information about the gene’s variation in population cohorts, and detailed information about related phenotypes. We also provide links to the references, abstracts, and variant databases used to help ordering providers further evaluate the reported findings if desired. The conclusion summarizes all of the existing information and provides our rationale for the classification of the variant.

Identification of pathogenic or likely pathogenic variants in dominant disorders or their combinations in different alleles in recessive disorders are considered molecular confirmation of the clinical diagnosis. In these cases, family member testing can be used for risk stratification. We do not recommend using variants of uncertain significance (VUS) for family member risk stratification or patient management. Genetic counseling is recommended.

Our interpretation team analyzes millions of variants from thousands of individuals with rare diseases. Our internal database and our understanding of variants and related phenotypes increases with every case analyzed. Our laboratory is therefore well-positioned to re-classify previously reported variants as new information becomes available. If a variant previously reported by Blueprint Genetics is re-classified, our laboratory will issue a follow-up statement to the original ordering healthcare provider at no additional cost, according to our latest follow-up reporting policy.