Review Article 205

Analysis of CYP1B1 Gene Mutations in Patients

with Primary Congenital Glaucoma
Leila Chouiter1 Sellama Nadifi2

1 Department of Medicine and Pharmacy, Hassan II University of Address for correspondence Sellama Nadifi, MD, PhD, Laboratory of
Casablanca, Casablanca, Morocco Medical Genetics and Molecular Pathology, Department of Medicine
2 Laboratory of Medical Genetics and Molecular Pathology, and Pharmacy, Hassan II University of Casablanca, 19 Rue Tarik Ibou
Department of Medicine and Pharmacy, Hassan II University of Ziad, B.P: 9154, Morocco (e-mail: nadifisel@yahoo.fr).
Casablanca, Casablanca, Morocco

J Pediatr Genet 2017;6:205–214.

Abstract Primary congenital glaucoma (PCG) is the most common type of infantile glaucoma,
yet it remains a relatively rare disease, because the disease is often transmitted in an

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autosomal recessive pattern. However, PCG occurs up to 10 times more frequently in
certain ethnic and geographical groups where consanguineous relationships are
common. The aim of this study was to investigate the distribution of mutations in
the cytochrome P450 1B1 gene (CYP1B1) in patients with PCG among different
populations around the world from 2011 until May 2016. We referred to the electronic
databases, such as Medline, Clinicalkey, Scopus, and ScienceDirect, to search for
articles that were published in this area. Nineteen records were included in this
qualitative synthesis. CYP1B1 mutations were assessed in 1,220 patients with PCG and
identified in 41.6% of them. According to these studies, 99 mutations including
60 novel mutations were found. Nonsignificant difference in the sex ratio has been
reported. This current review shows that consanguinity plays an important role in the
PCG pathogenesis and transmission; however, sporadic mutations have been found in
some cases. A difference in penetrance was highlighted by some mutations. The
CYP1B1 mutations were mostly found in the Middle East and the Maghreb with a rate of
64.8 and 54.4%, respectively, followed by Europe (34.7%), Asia (21.3%), and finally the
United States (14.9%). Founder mutations in different geographical areas have been
discovered. For instance, the p.Gly61Glu, p.Arg390His, p.Gly61Glu, c.4,339delG,
p.E387Lys, and p.Val320Leu were considered founder mutations for Iran/Saudi Arabia,
Keywords Pakistan, Lebanon, Morocco, Europe, and Vietnam/South Korea, respectively. Many
► primary congenital common mutations in different countries were found, such as in Morocco, where its
glaucoma mutations were similar to seven other countries. These findings suggest that the ethnic
► CYP1B1 differences and the geographical distribution of PCG give us a large CYP1B1 mutation
► cytochrome P450 pattern. Genetic tests looking for founder and common mutations should be the first
► GLC3A step in genetic screening for patients with PCG.

Introduction disease with an incomplete penetrance.1 PCG is character-

ized by elevated intraocular pressure (IOP), buphthalmos,
Primary congenital glaucoma (PCG) is a rare form of glau- edema, and opacification of the cornea with rupture of
coma and is usually transmitted as an autosomal recessive Descemet’s membrane, thinning of the anterior sclera and

received Copyright © 2017 by Thieme Medical DOI https://doi.org/

January 8, 2017 Publishers, 333 Seventh Avenue, New 10.1055/s-0037-1602695.
accepted after revision York, NY 10001, USA. ISSN 2146-4596.
March 22, 2017
published online
April 21, 2017
206 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi

iris atrophy, anomalously deep anterior chamber, and struc-

Methods
turally normal posterior segment except for progressive
glaucomatous optic atrophy. Symptoms include photopho- Search Strategy
bia, blepharospasm, and hyperlacrimation. Typically, the An extensive search was conducted in MEDLINE (2011 to
diagnosis is made in the first year of life. In untreated cases, May 2016), ScienceDirect (2011 to May 2016), Scopus (2011
blindness invariably occurs. The diagnosis of PCG is based to May 2016), and Clinicalkey (2012 to May 2016) for articles
on clinical findings, but the genetic tests may confirm the that have been published until May 2016, by using a combi-
diagnosis. Some attempts in understanding the molecular nation of keywords (CYP1B1, cytochrome P450, GLC3A, PCG).
basis through genome-wide association studies and whole Based on the first screening of the titles and abstracts, the
genome resequencing approaches are under way and studies were selected. A full screen was conducted to exclude
may provide valuable insight regarding the underlying studies that did not meet inclusion criteria.
mechanisms.
Different PCG loci have been mapped, in contrast, cyto- Inclusion Criteria
chrome P450, family 1, subfamily B, polypeptide 1 (CYP1B1) This review includes all studies that met the following
remains the only gene identified to date. More than 150 inclusion criteria:
mutations including missense, nonsense, regulatory, and
1. Selecting only PCG patients with CYP1B1 mutations either
insertions and/or deletions in CYP1B1 have been associated
in comparative studies with other types of glaucoma or
to PCG,2 and are the main known cause of PCG. The CYP1B1

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gene
gene contains three exons, and the coding region starts
2. Performing a mutational analysis of CYP1B1 gene
within the second exon. The 543-amino acids long CYP1B1
3. Reporting the exact DNA sequence alteration
protein belongs to the cytochrome P450 family, a group of
4. Disqualifying patients known to carry a systemic syndrome
heme-thiolate monooxygenases. In liver microsomes, this
or other ocular pathology associated with glaucoma
enzyme is involved in a nicotinamide adenine dinucleotide
5. Retaining a mutation only once if several members of the
phosphate (NADP)-oxidase–dependent electron transport
same family had the same mutation
pathway. The enzyme oxidizes various structurally unrelated
compounds, including steroids, fatty acids, and xenobiotics.
Results
CYP1B1 participates in the metabolism of an unknown
biologically active molecule that contributes to eye Total 68 records were identified, from which 2 duplicate
development.3 records were removed. Titles and abstracts of 66 records
Although the exact function of CYP1B1 protein in the eye were screened and 49 records were excluded because they
is still unclear, but as it is a mono-oxygenase, some scenarios did not meet the defined inclusion criteria. The full texts of
may be expected for its role in the development of the eye. the remaining 19 reports were examined.
Mutations in CYP1B1 might result in the absence of its Based on these reviewed studies, CYP1B1 mutations have
responsible morphogen for the trabecular meshwork (TM) been searched in 1,220 PCG patients and identified in 508
development and the outflow system, which in turn alters patients with a rate of 41.6%. ►Table 1 shows the number of
the expression of genes.4 They may also result in the accu- PCG patients and CYP1B1 mutation carriers.
mulation of some active morphogen that should be elimi-
nated, producing toxic effects, which in turn may lead to CYP1B1 Mutations in Different Populations
developmental arrest.4 In addition, abnormalities in the TM The percentage of CYP1B1 mutations varies among different
structure could result in the disease phenotype, based on a ethnic groups and geographical areas, where the Middle East
study, that has compared trabeculectomy specimens of con- is predominant with a percentage of 64.8%, followed by the
genital glaucoma patients with normal human eyes at a Maghreb (54.4%), Europe (34.7%), Asia (21.3%, except India),
histologic and ultrastructural level.5 and then the United States with 14.9%.
A CYP1B1 mutation is the predominant cause of inherited According to the provided data, the sex ratio of patients
PCG. To date, several mutations have been identified in with PCG and those with CYP1B1 mutations was almost
patients and families with PCG from numerous countries similar (1.11 and 1.09, respectively).
and ethnic groups.
In this current review, we describe 99 distinct CYP1B1 Discovered Mutations
mutations that we have retrieved from various studies. In By removing the repeated mutations, 99 mutations were
addition, we analyze the spectrum of CYP1B1 mutations in found in 508 patients, with 39 already identified in the study
different populations. of Li et al (2011).6
The benefit of this qualitative synthesis is to highlight the In this current review, 60 novel unlisted mutations have
involvement and the impact of CYP1B1 mutations in different been reported from 2011 until May 2016 (►Table 2).
ethnical and geographical areas in the world. These informa-
tions can identify populations at a particular risk, provide a Founder Mutations
more reliable genetic test/counseling, and also guide the After analyzing the different included studies, some muta-
clinician in managing the harm of PCG by suggesting pre- tions were more frequent and widespread than others. These
dictive testing and better prognosis. mutations can be considered as founder mutations to each

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 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi 207

Table 1 Number of PCG patients and CYP1B1 mutations carriers

Studies Ethnicity Total no. of PCG patients M F No. of patients M F

with CYP1B1
mutations
Do et al, (2016)35 Vietnamese 30 17 13 5 2 3
Al-Haddad et al, (2016)9 Lebanese 18 9 9 6 3 3
8
Abu-Amero et al, (2016) Saudi 1 0 1 0 0 1
36
Yazdani et al, (2016) Iranian 17 6 1 10 4 6
Morales-Fernandez et al, (2015)37 Spanish 3 2 1 3 2 1
32
Chen et al, (2015) Chinese 2 2 0 3 3 0
38
Cardoso et al, (2015) Portuguese 21 14 7 6 NM NM
Berraho et al, (2015)39 Moroccan 94 53 41 51 27 24
40
de Melo et al, (2015) Indian/Brazilian India: 301 NM NM India: 132 NM NM
Brazil: 150 Brazil: 66
Vogt et al, (August 2014)41 Roma (Hungary) 1 1 0 1 1 0

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16
Bouyacoub et al, (2014) Tunisian 18 5 13 10 5 5
42
Chen et al, (2014) Chinese 122 NM NM 21 NM NM
Sheikh et al, (2014)43 Pakistani 36 21 15 36 21 15
Badeeb M et al, (2014)7 Saudi 34 21 13 27 NM NM
Saudi: 23 14 9 Saudi: 21
Non-Saudi: 11 7 4 Non-Saudi: 6
(Yemen: 4
Sudan: 3 Afghanistan: 2
Burma: 1
Syria: 1)
López-Garrido et al, (2013)10 European 161 88 73 56 NM NM
34
Lim et al, (2013) United States 47 26 21 12 6 6
Khan et al, (2012)44 Saudi 5 3 2 0 0 0
45
Suh and Kee, (2012) Korean 85 46 49 22 10 12
46
Abu-Amero et al, (2011) Saudi 74 38 36 41 21 20

Abbreviations: F, female; M, male; NM, not mentioned.

geographic area. ►Table 3 lists some examples of these the c.868_869insC, p.Glu229Lys, and Ala115Pro have each
founder mutations. been found only once in three families.
In Lebanon, the most common mutation was p.Gly61Glu.
Middle East CYP1B1 mutations in Lebanese patients are rarer compared
In the Iranian population, the most common mutation was with the Middle East and other Arab populations. This is
p.Gly61Glu. It was found in two homozygous patients and in probably because the Lebanese originated from a mix of
one heterozygous patient, followed by p.Arg390His identi- European and Asian populations, providing a wider genetic
fied in two homozygous patients. heterogeneity in Lebanese families, whereas homozygosity is
In Saudi Arabia, the p.Gly61Glu mutation is considered as more common in the Arab population.9
the major mutation, found 17 times in the homozygous state
and once in the heterozygous state.7 Findings from Saudi Maghreb
Arabia suggest that novel PCG genes are more likely to arise In Morocco, among the mutation carriers, 62.7% (32/51) had
in their population. However, in other case reports, not any frameshift truncating mutations (g.4339delG, g.4330–
CYP1B1 mutations were found, where the glaucoma was 4331delTG, and g.79016–7913del13bp) in both alleles, and
probably related to novel CNVs (copy number variations).8 37.3% (19/51) had at least one missense mutation (nine patients
Another example of Saudi Arabian children, affected by were homozygous for p.Arg390Ser, p.Arg469Trp, p.Cys470Tyr,
unilateral PCG, where no CYP1B1 mutation was detected, or p.Gly61Glu; eight patients were compound heterozygous,
suggests that the pathogenesis of unilateral glaucoma differs including (5) p.Glu173Lys, (2) p.Gly61Glu, (1) p.V364M ,and two
from the bilateral form. heterozygous for p.Arg163Cys and p.Arg368His, respectively).
In Pakistan, the p.Arg390His mutation was the most In Tunisia, the CYP1B1 mutations were present in 55%
common, identified in five families (50%, 5/10), whereas of the patient’s alleles. Two mutations p.Gly61Glu and

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208 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi

Table 2 List of new unlisted CYP1B1 mutations

Population Location genomic DNA Amino acid change Type of N Homozygote Heterozygote
scheduled change mutation
Vietnamese Exon 2 c.836A > T p.His279Leu NM 1 þ
Vietnamese Exon 2 c.847C > T p.Leu283Phe NM 1 þ
Lebanese NM 1793delC p.Ser464 Frameshift 1 þ
Iranian NM NM p.Tyr81 NM 1 þ
Iranian NM NM p.Arg390His NM 2 þ
Iranian-Saudi Exon 2 c.685G > A p.Glu229Lys Missense 1 þ þ
1
Iranian NM NM p.Pro289fs NM 1 þ
Iranian NM NM p.Gly329Val NM 1 þ
Iranian NM NM p.Arg368Cys NM 1 þ
Spanish NM NM p.Thr404fsX38 NM NM NM
Moroccan NM g.4339delG NM Frameshift þ

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Moroccan NM g.4330–4331delTG NM Frameshift NM þ
Moroccan NM g.79016–7913del13bp NM Frameshift NM þ
Indian- NM 8263T > C p.Ser476Pro NM 1 NM
Brazilian 1
Indian- NM 8214_8215delAG p.Val460fs NM 2 NM
Brazilian 3
Indian NM g.3925delG p.Arg41fs NM NM NM
Indian NM g.3972C > T p.Ala56Val NM NM NM
Indian NM g.4055 G > T p.Val84Phe NM NM NM
Indian NM g.4095T > C p.Leu97Pro NM NM NM
Indian NM g.4197C > G p.Ser131Arg NM NM NM
Indian NM g.4347T > C p.Leu181Pro NM NM NM
Indian NM g.4421_4423del p.205delS NM NM NM
Indian NM g.4641A > C p.His279Pro NM NM NM
Indian NM g.4793G > A p.Ala330Thr NM NM NM
Indian NM g.7917G > A p.Leu360L NM NM NM
Indian NM g.7949G > T p.Cys371Phe NM NM NM
Indian NM g.8148del5bp p.Pro437fs NM NM NM
Indian NM g.8162C > T p.Pro442Leu NM NM NM
Indian NM g.8227T > C p.Ser464Pro NM NM NM
Indian NM g.8393A > G p.Asn519Ser NM NM NM
Brazilian NM g.4523delC p.Leu240fs NM NM NM
Portuguese- Exon 2 c.317C > A p.Ala106Asp Missense NM þ
United States ch
Portuguese Exon 3 c.1390dupT p.Ser464fs Frameshift NM þ
Pakistani NM NM p.Gly36Asp Missense 4 þ
Pakistani NM NM p.Gly67-Ala70del Frameshift 2 þ
Chinese NM g.T3836C p.Trp11Arg Missense NM þ ch
Chinese NM g.4022delTC p.73, stop at p.221 Frameshift NM ch
Chinese NM g.G4151T p.Asp116Tyr Missense NM þ ch
Chinese NM g.T4338A p.Val178Glu Missense NM þ ch
Chinese NM g.G4493A p.Glu230Lys Missense NM þ ch
Chinese NM g.T4509C p.Val235Ala Missense NM þ
Chinese NM g.T8137C p.Trp434Arg Missense NM þ
Chinese NM g.C8167T p.Arg444 Nonsense NM þ ch

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 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi 209

Table 2 (Continued)

Population Location genomic DNA Amino acid change Type of N Homozygote Heterozygote
scheduled change mutation
Chinese NM g.G4322A p.Glu173Lys Missense NM þ ch
Tunisian NM 691T > A p.Phe231Ile NM 1 þ
Tunisian NM c.1309C > G p.Pro437Ala NM 1 þ
European Exon 1 c.337G > T NM NM NM NM
European Exon 2 NM p.Phe123Leu NM NM þ
European Exon 2 I399_P400del NM NM NM ch
European NM NM p.Ala237Glu NM NM NM
United States NM c.1063C > T p.Arg355 Nonsense NM 1þ
United States NM c.171G > A p.Trp57 Nonsense NM þ
United States NM c.1209_1210insTCATGCCACC 10-bp insertion Frameshift NM NM
United States NM c.1064_1076delGAGTGCAGGCAGA 13-bp deletion Frameshift frame NM NM
Korean NM c.970_971dupAT p.Thr325SerfsX104 NM NM þ

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Korean NM c.985G > A p.Gly329Ser NM NM þ
Korean NM c. 1256_1257delTG p.Val419GlyfsX11 NM NM ch
Saudi NM g.4160G > T p.Ala119Ser Missense NM NM
Saudi NM g.8159A > G p.Asp441Gly Missense NM NM
Saudi NM g.8233G > A p.Gly466Ser Missense NM NM

Abbreviations: (þ), present; ch, compound heterozygous; N, number; NM, not mentioned.

c.535delG were identified in a homozygous state in seven United States

patients and two probands, respectively. Five novel combinations of compound heterozygous muta-
tions were identified, of which two were found with whole
Asia exome sequencing.
In Vietnam, only 5/30 of PCG patients have been associated
with CYP1B1 alterations. CYP1B1 is not considered as the India and Brazil
major gene involved in the Vietnamese population compared In a comparative study between India and Brazil, the patients
with the Arab and Gypsy patients. had a large spectrum of common mutations: p.Arg368His; p.
In a Chinese case report, the mutation c.517G > A/p. Pro437Leu; p.Ala443Gly; p.Ser476Pro; p.Thr404fsX30; p.
Glu173Lys was detected in a homozygous state in two Val460fs.
affected individuals but also in a nonaffected individual,
which could refer to an incomplete penetrance. Common Mutations among Different Populations
Almost 20 similar mutations have been discovered in differ-
Europe ent countries and continents. ►Table 4 links each mutation
In the European study, 31 different mutations have been to the countries where it was identified.
discovered, of which 56% were compound heterozygous and From these mutations (p.Gly61Glu, p.Val320Leu,
25% homozygous. p.Arg469Trp, p.Gly61Glu, p.Glu173Lys, p.Val364Met,

Table 3 Specific founder mutations from each geographic area

Geographical area Location Genomic DNA Change

amino acid/scheduled change
Morocco Exon 2 g.4339delG Frameshift
Saudi Arabia Exon 2 c.182G > A p.Gly61Glu
Iran Exon 2 c.182G > A p.Gly61Glu
Lebanon Exon 2 3987G > A p.Gly61Glu
Pakistan Exon 3 8006G > A p.Arg390His
Europe Exon 3 7996G > A p.Glu387Lys
Vietnam South Korea Exon 2 958G > T p.Val320Leu

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210 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi

Table 4 Common mutations in different countries

Location Genomic DNA Amino acid change/scheduled change Type mutations Country Consanguinity
Exon 2 3987G > A p.Gly61Glu Missense Lebanon þ
Morocco þ
Tunisia þ
Saudi Arabia þ
Exon 2 958G > T p.Val320Leu Missense Vietnam 
South Korea 
Exon 3 8242C > T p.Arg469Trp Missense Lebanon þ
Morocco þ
Saudi Arabia þ
Exon 2 182G > A p.Gly61Glu Missense Iran þ
Portugal NM
Saudi Arabia þ
Exon 2 4322G > A p.Glu173Lys Missense China NM
Morocco þ
Exon 3 7927G > A p.Val364Met Missense South Korea 

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Morocco þ
Exon 3 7940G > A p.Arg368His Missense Brazil þ
India þ
Morocco þ
South Korea 
Exon 3 8147C > T p.Pro437Leu Missense India þ
Brazil þ
Saudi Arabia þ
Exon 3 8165C > G p.Ala443Gly Missense India þ
Brazil þ
Saudi Arabia þ
NM 8263 T > C p.Ser476Pro NM India þ
Brazil þ
NM 8037_8046dup10 p.Thr404fsX30 NM India þ
Brazil þ
NM 8214_8215delAG p.Val460fs NM India þ
Brazil þ
Exon 2 317C > A p.Ala106Asp Missense Portugal NM
United States NM
Exon 3 1159G > A p.Glu387Lys Missense Portugal NM
United States NM
Exon 3 8006G > A p.Arg390His Missense Pakistan þ
Saudi Arabia þ
Korea 
Exon 2 4490G > A p.Glu229Lys Missense Lebanon þ
Pakistan þ
Exon 2 685 g > A p.Glu229Lys Missense Saudi Arabia þ
Iran þ
Exon 3 8168G > A p.Arg444Gln Missense Korea 
Lebanon þ
Exon 2 535delG p.Ala179fs Frameshift Portugal NM
Tunisia þ
Exon 3 7996G > A p.Glu387Lys Missense Europe þ
Hungary NM

Abbreviations: (þ), positive; (), negative; NM, not mentioned.

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 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi 211

p.Arg368His, p.Pro437Leu, p.Ala443Gly, p.Ala106Asp, p. This review also revealed a nonsignificant difference in
Glu387Lys, p.Arg390His, p.Glu229Lys, p.Glu229Lys, p. the sex ratio between different ethnic groups and CYP1B1
Arg444Gln, p.Ala179fs, p.Glu387Lys), 47.1% locate in exon mutation carriers.
2 and 52.9% in exon 3, respectively.
All the common mutations had almost the same mutation In the Middle-East
type in missense except for the frameshift mutation p. According to Li et al,6 the 3987G > A (p.Gly61Glu) seemed to
Ala179fs. be the most common mutation in Middle Easterners, ac-
Morocco had similar mutations to other countries such as counting for 45.52% (183 out of 402) of CYP1B1 mutations.
Lebanon, Tunisia, Saudi Arabia, China, South Korea, Brazil, The other common mutations were 8006G > A (p.Ar-
and India. g390His) (8.71%), 8242C > T (p.Arg469Trp) (8.21%), and
Asian patients such as South Korean have no consangui- 4339delG (5.72%).
nity status, yet they showed the same mutations as countries In comparison with this current review, the p.Gly61Glu
where the consanguinity is quite high as: 7927G > A/p. mutation was also prominent. It was discovered in four
Val364Met, 7940G > A/p.Afg368His, 8006G > A/Arg390His, different countries with a high rate of consanguinity, such
and 8168G > A/p.Arg444Gln. as Morocco, Tunisia, Lebanon, and Saudi Arabia. According to
Nevertheless, the 958G > T/p.Val320Leu remains the mu- the literature, this mutation was also found in other coun-
tation observed only in Asia (Vietnam and South Korea). tries such as Ecuador, Spain, India, Iran, Oman, Kuwait,

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Turkey, and especially in Saudi Arabia, where it was demon-
strated as the founder mutation. This mutation has been
Discussion
introduced into North Africa and Southern Europe during the
Advances in genetics studies of glaucoma have shown that Arab invasion in the seventh century.16 The Saudi study also
some PCG cases are the outcome of an autosomal recessive confirms that CYP1B1 mutations are the most common cause
inheritance pattern, despite the fact that it has traditionally of PGC in their population, with the p.Gly61Glu as the main
been considered as sporadic. The PCG disease is genetically mutation.7 This mutation has also been discovered in Iran
heterogeneous and may be caused by modifications in at least and Portugal.
three different genes. To date, mutations in the CYP1B1 gene According to the literature, the p.Arg390His mutation was
remain the main known genetic cause of PCG.10–12 The main detected for the first time in a Pakistani patient.17 It was the
characteristic feature of PCG is an abnormal iridocorneal angle. most common mutation in the Pakistani population with 50%
More specifically, the TM impedes the normal outflow of of CYP1B1 alleles (5/10) and 25% of PCG families (5/20). It was
aqueous humor with the consequence of elevating IOP. The not only found in Pakistan but also in Saudi Arabia and South
CYP1B1 protei belongs to the cytochrome P450 superfamily of Korea, known to have a high and low rate of consanguinity,
enzymes and has been implicated in the development of ocular respectively. It could therefore be a sporadic or familial
structures, involved in aqueous humor drainage through its mutation. According to the literature, this mutation has
action as a monooxygenase enzyme.13 CYP1B1 mutations in been described as the second most frequent mutation among
the presence of tyrosinase (TYR) deficiency develop a more Indian and Iranian patients suffering from congenital glau-
severe phenotype, immediately suggesting TYR as a modifier coma, representing 16 and 19.2%, respectively.18,19
gene.14 TYR deficiency is also found in patients with anterior The p.Arg469Trp mutation was found in the following
segment dysgenesis (ASD) and albinism.15 Gene-gene interac- countries: Lebanon, Saudi Arabia, and Morocco. It has also
tion studies might lead to proper understanding of the disease been found in different populations, including the Middle
pathogenesis and consequently revealing probable mechan- East, Arab, European, and Asian.20–22
isms for therapy required. The p.Glu229Lys and p.Arg444Gln mutations were iden-
Extensive analysis of the CYP1B1 gene in PCG patients in tified in a Lebanese family. Although the mutation p.
various populations around the world has revealed a great Glu229Lys was described in several ethnic groups,20,23,24
diversity, reflecting at the same time a similar mutation the p.Arg444Gln has never been reported before in the
spectrum of the CYP1B1 gene in the pathogenesis of the Arab population. However, it has been reported in Japanese,
disease. French,25,26 and Korean patients.
In this meta-analysis, the CYP1B1 mutations were identi-
fied in 41.6% of the patients, which underlines its importance Maghreb
in PCG pathogenesis. However, other possibilities causing In the Tunisian study, there is a great probability that the p.
PCG (unknown regulatory loci, genes phenocopying PCG, Gly61Glu, 535delG, and two novel mutations p.Phe231Ile
mutations in modifier genes) should be suggested for the and p.Pro437Ala come from a common ancestor. Screening
58.2% remaining patients. for the presence of these mutations should improve the
In addition, 99 mutations were found and 60 of them were genetic diagnosis and reduce the blindness due to late PCG
novel compared with the study of Li et al.6 diagnosis.
The prevalence of CYP1B1 mutations shows a vast geo- In Morocco, the first analysis of CYP1B1 mutations in the
graphic variability where the Middle East and the Maghreb Moroccan population was performed in isolated cases, more
were predominant correlated to high rate of consanguinity, than 14 years ago. Two mutations were identified:
followed by Europe, Asia, and United States. g.4339delG and p.Gly61Glu. The novel frameshift mutation

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212 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi

g.4339delG was never described before and was considered identified in an Egyptian family and later reported among
the most frequent (25.8% of alleles). Nevertheless, it had been Iranian patients.18,33 It has also been found in Morocco.
found in Algerian descendants (E. Colomb and HJ Garchon,
unpublished data). Therefore, this should be closely related Europe
to the presence of the Berber people, representing a major The p.Glu387Lys is considered the most common mutation.
part of the Algerian and Moroccan population. The other This mutation was also found in a Hungarian patient in the
mutation, p.Gly61Glu, had already been identified in Turkish homozygous state where both parents were heterozygous. It
and Saudi patients.27 was also demonstrated that this mutation was the most
Since the myocilin (MYOC) gene has also been found to be frequent in Gypsy population.9
involved in the etiology of the PCG, another Moroccan study
was conducted to assess the mutation spectrum of both, the United States
CYP1B1 and MYOC gene. The CYP1B1 gene was the major In the United States study, two novel combinations of
cause of GCP with a frequency of 48%, while MYOC played compound heterozygous mutations have been found with
only a modest role in Moroccan patients. The g.4339delG whole exome sequencing. Whole exome sequencing,
mutation was the most frequent followed by p.Gly61Glu. coupled with Sanger sequencing, may identify novel genes
These two mutations were present in 37.21% (30.55% and for PCG patients who do not harbor mutations in known
6.66%, respectively) of the Moroccan alleles. The g.4339delG PCG genes.
was also the most common mutation in Brazil23 with a lower

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However, CYP1B1 mutations are less common in the
rate compared with Morocco (21%). Three mutations were United States (14.9%) than in other Arab or Gypsies countries.
novel (p.Arg163Cys, p.Cys470Tyr, and g.4330–4331delTG) This highlights the fact that other genes may account for PCG
and five were identified for the first time in the African in the U.S. population, reinforcing the idea that it is an ocular
population (p.Arg368His, p.Val364Met, p.Arg390Ser, p. disease of genetic heterogeneity.34
Arg469Trp, and g.7901–7913del13bp).28 Other mutations
(p.Gly61Glu, p.Glu173Lys, and g.4339delG) have already India and Brazil
been reported in different populations.29 These countries have significant allelic heterogeneity with
All these mutations have been described in the Moroccan the R368H and 4340delG mutations because they prevail in
study included in our meta-analysis; 62.7% (32/51) of pa- India and Brazil, respectively. Interestingly, the most com-
tients had mutations (4339delG, g.4330–4331delTG and mon mutation in Brazil 4340delG was not observed in the
g.79016–7913del13bp) in both alleles. Indian population, and R368H was observed only in three
The 4339delG mutation was found widely in different Brazilian patients in the homozygous or compound hetero-
Moroccan studies. It may therefore be a founder mutation for zygous state.
the Moroccan population.

Conclusion
Asia
According to the study conducted by Li et al, the three most In this meta-analysis, 99 CYP1B1 gene mutations causing PCG
common mutations in Asian patients were p.Val364Met, p. from 2011 until May 2016 were identified. Moreover, 60 new
Arg390His, and p.Leu385Phe.9 mutations, not listed in the reference study of Li et al,6 were
In this meta-analysis, both p.Val364Met and p.Arg390His reported.
mutations were identified in South Korea, but also in Mor- CYP1B1 mutations were identified in 41.6% of the pa-
occo and in some Middle East countries (Saudi Arabia, and tients, which underlines the importance of CYP1B1 muta-
Pakistan). tional analysis. Therefore, other possibilities may cause the
On the other hand, the p.Leu385Phe was not found either PCG for the remaining 58.2% patients.
in Asian population or in other ethnic groups. It could be a Nonsignificant difference in the sex prevalence between
mutation that had stopped being transmitted through gen- different ethnic groups has been reported.
erations or not found in our sample of patients. Consanguinity plays an important role in the pathogen-
The p.Val320Leu mutation appeared only in Asian coun- esis and the transmission of PCG; however, some sporadic
tries including Vietnam and South Korea, where the con- mutations were also found. A difference in the penetrance for
sanguinity rate is low. This mutation has also been reported the same mutation was also highlighted in affected and
previously in the Chinese and Japanese population30,31 nonaffected Chinese individuals in this review.
suggesting that she could be a specific mutation for the The mutations distribution and frequency vary consider-
Asian population. ably between different ethnic and geographic locations.
The mutation p.Glu173Lys was detected in two Chinese The G61E was the most frequent mutation and was
patients and also in a nonaffected patient, which could be discovered in four different countries where the consangui-
explained by an incomplete penetrance. It suggested the nity rate is high.
presence of a dominant modifier locus that is not genetically Some mutations may be considered as founder mutations
linked to CYP1B1. Further studies of a possible regulation of for different populations. For example, the Gly61Glu, R390H,
other factors or other genes (e.g., LTBP2) should be performed G61E, 4339delG, E387K, and V320L were estimated as foun-
to explore the pathogenesis of PCG.32 This mutation was first der mutations for these countries: Iran/Saudi Arabia,

Journal of Pediatric Genetics Vol. 6 No. 4/2017

 Analysis of CYP1B1 Gene Mutations in Patients with PCG Chouiter, Nadifi 213

Pakistan, Lebanon, Morocco, Europe, and Vietnam/South 13 Stoilov I, Akarsu AN, Sarfarazi M. Identification of three different
Korea, respectively. truncating mutations in cytochrome P4501B1 (CYP1B1) as the
In addition, many common mutations in different coun- principal cause of primary congenital glaucoma (Buphthalmos) in
families linked to the GLC3A locus on chromosome 2p21. Hum
tries were found, such as Morocco where its mutations were
Mol Genet 1997;6(04):641–647
similar to seven other countries. 14 Libby RT, Smith RS, Savinova OV, et al. Modification of ocular
This overview provides a CYP1B1 mutations spectrum, defects in mouse developmental glaucoma models by tyrosinase.
causing GCP in different populations. Science 2003;299(5612):1578–1581
Genetic tests looking for common and specially founder 15 van Dorp DB, Delleman JW, Loewer-Sieger DH. Oculocutaneous
albinism and anterior chambre cleavage malformations. Not a
mutations should be the first step in genetic screening for
coincidence. Clin Genet 1984;26(05):440–444
PCG patients.
16 Bouyacoub Y, Ben Yahia S, Abroug N, et al. CYP1B1 gene mutations
Despite the fact that CYP1B1 alone cannot explain the causing primary congenital glaucoma in Tunisia. Ann Hum Genet
overall genetic contributions to PCG, it is still a promising 2014;78(04):255–263
development. Its role in classic cases of PCG and those devoid 17 Stoilov I, Akarsu AN, Alozie I, et al. Sequence analysis and
of mutations in CYP1B1 would be interesting. In fact, more homology modeling suggest that primary congenital glaucoma
on 2p21 results from mutations disrupting either the hinge region
scientific studies should be done in the future to approach
or the conserved core structures of cytochrome P4501B1. Am J
the exact PCG cause, because of the complexity and the Hum Genet 1998;62(03):573–584
genetic heterogeneity. 18 Chitsazian F, Tusi BK, Elahi E, et al. CYP1B1 mutation profile of

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This overview can be helpful in developing reliable genetic Iranian primary congenital glaucoma patients and associated
tests for PCG patients and their families. haplotypes. J Mol Diagn 2007;9(03):382–393
19 Tanwar M, Dada T, Sihota R, Das TK, Yadav U, Dada R. Mutation
spectrum of CYP1B1 in North Indian congenital glaucoma pa-
Funding tients. Mol Vis 2009;15:1200–1209
None. 20 Geyer O, Wolf A, Levinger E, et al. Genotype/phenotype correla-
tion in primary congenital glaucoma patients from different
ethnic groups of the Israeli population. Am J Ophthalmol 2011;
Conflict of Interest 151(02):263–271.e1
None. 21 Campos-Mollo E, López-Garrido MP, Blanco-Marchite C, et al.
CYP1B1 mutations in Spanish patients with primary congenital
glaucoma: phenotypic and functional variability. Mol Vis 2009;
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