American Journal of Medical Genetics 73:267–271 (1997)
Tandem Duplication of 11p12-p13 in a Child With
Borderline Development Delay and Eye
Abnormalities: Dose Effect of the PAX6 Gene Product?
C.M. Aalfs,1* J.A. Fantes,2 L.J.J.M. Wenniger-Prick,3 S. Sluijter,1 R.C.M. Hennekam,1,4
V. van Heyningen,2 and J.M.N. Hoovers1
1
Institute of Human Genetics, Academic Medical Center, Amsterdam, The Netherlands
2
MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh, United Kingdom
3
Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands
4
Department of Pediatrics, Academic Medical Center, Amsterdam, The Netherlands
We report on a girl with a duplication of
chromosome band 11p12→13, which in-
cludes the Wilms tumor gene (WT1) and the
aniridia gene (PAX6). The girl had border-
line developmental delay, mild facial
anomalies, and eye abnormalities. Eye find-
ings were also present in most of the 11
other published cases with partial trisomy
11p, including 11p12→13. Recently, it was
shown that introduction of additional cop-
ies of the PAX6 gene into mice caused very
variable eye abnormalities. Therefore, a
PAX6 gene dosage effect is likely to be pres-
ent in mice and humans. The central ner-
vous system may be less sensitive to an al-
tered PAX6 gene dosage, which is consistent
with the borderline developmental delay in
the present patient. Urogenital abnormali-
ties were absent in this patient and in most
of the other patients with partial trisomy of
11p. Therefore, the effect of a WT1 gene du-
plication on the embryological development
of the urogenital tract remains uncertain.
Am. J. Med. Genet. 73:267–271, 1997.
© 1997 Wiley-Liss, Inc.
KEY WORDS: trisomy 11p; eye abnormali-
ties; developmental delay;
PAX6 gene; WT1 gene; gene
dosage effect
INTRODUCTION
Mutations in the PAX6 gene are responsible for the
semidominant panocular disorder aniridia [Hanson
and van Heyningen, 1995] and the classical mouse mu-
*Correspondence to: Dr. C.M. Aalfs, Institute of Human Genet-
ics, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
Received 9 December 1996; Accepted 19 May 1997
© 1997 Wiley-Liss, Inc.
tation small eye [Hill et al., 1991]. The PAX6 gene is
one of the increasing vertebrate genes in which loss-of-
function mutations result in dominant developmental
phenotypes, suggesting a gene dosage effect. In hu-
mans, a PAX6 gene dosage effect was illustrated by
Glaser et al. [1994], who studied two different muta-
tions segregating in a single family. The range of eye
findings in this family correlated with the level of
PAX6 activity. Using a transgenic approach, additional
copies of the PAX6 gene were introduced into the
mouse genome [Schedl et al., 1996]. The transgenic
strains showed variable eye abnormalities, ranging
from an almost normal external appearance to severe
microphthalmia. This also indicates a detrimental ef-
fect of increased PAX6 gene expression.
Recently, we investigated a patient with eye abnor-
malities, mild facial anomalies, and slight developmen-
tal delay. Cytogenetic and molecular studies showed a
duplication of 11p12→13, which included the PAX6 re-
gion. Comparison was made to other reported cases
with partial trisomy 11p, with special attention to ocu-
lar anomalies.
CLINICAL REPORT
The proposita was born at term to a 31-year-old fa-
ther and a 28-year-old mother, after an uneventful
pregnancy and delivery. The nonconsanguineous par-
ents and brothers and sisters were healthy. The
mother had had one spontaneous early abortion.
At birth the weight was 3,975 g and length was 52
cm. The neonatal period was uneventful. At 3 months,
the girl was investigated because of suspicion of visual
problems. Ophthalmological investigations showed
only an alternating convergent strabismus with cross-
fixation, which was at least partly due to hypermetro-
pia. Physical findings, results of routine blood investi-
gations, electroencephalography, and brain, renal, and
cardiac sonography were normal. Length, weight, and
head circumference were all about the 10th centile.
Repeated examination at 5 months showed mild fa-
cial abnormalities consisting of some midface hypopla-
268 Aalfs et al.

sia, small and deeply set eyes, a relatively broad nasal

bridge, and a small mouth (Fig. 1, Table I). Mild taper-
ing of the fingers was noticed. When the girl started to
chew solid foods, the parents noticed that the lower
eyelids moved downwards while she was eating. She
suffered from a chronic constipation, for which no spe-
cific cause could be found. Psychomotor development
was mildly delayed. She started to smile at 5 months,
sat at 8 months, and started to walk at 15 months. At
20 months, she started to speak. In addition to the
strabismus and hypermetropia, ophthalmological ex-
amination showed a slight nystagmus, a marginal cor-
neal diameter (10.5 mm), and mild abnormalities of the
fundus of the right eye, consisting of a somewhat pale
optic disc and three small atrophic regions in the jux-
tapapillary choroid. Slitlamp examination of the ante-
rior segment was performed and pictures were taken
(Fig. 2). Both corneae were clear with a normal curva-
ture and a diameter of 11.0 mm. The anterior chamber
and pupils were normal. The iris stroma was very hy-
poplastic, especially in the peripheral region, where
iris translucency was present.

CYTOGENETIC ANALYSIS
Routine chromosome analysis of G-banded prometa-
phase chromosomes from peripheral blood lymphocytes
showed extra chromosomal material in the short arm of
chromosome 11 (Fig. 3). Chromosome analysis of both
parents was normal.
FLUORESCENCE IN SITU HYBRIDIZATION
(FISH) AND DNA STUDIES
The duplication within 11p was characterized in de-
tail by FISH analysis. Methodology and cosmid probes
were described elsewhere [Fantes et al., 1995]. The du-
plication spanned approximately 2 Mb and included
two known genes, the Wilms tumor gene (WT1) and the
aniridia gene (PAX6). The proximal breakpoint lies be-
tween cosmids c65-6/13 (D11S104) and cCI11-464
(D11S676) in p12, the distal breakpoint between 591/1
(D11S995) and AO4160 (D11S317) in p13 (Table II).
The order of signals using cosmids C1-11-458
(D11S672) and 591/1 (D11S995) in interphase nuclei
demonstrates a tandem duplication. Representative
FISH pictures are shown in Figure 4.
DISCUSSION
Complete or partial trisomy of 11p, including 11p13,
was described before in 11 cases [Aleck et al., 1985;
Falk et al., 1973; Fryns et al., 1981, 1985; Lavedan et
al., 1989; Ogur et al., 1988; Palmer et al., 1976; Palutke
et al., 1980; Sanchez et al., 1974; Speleman et al., 1991;
Strobel et al., 1980]. In two of these cases, the duplica-
tion was de novo. In nine others, it resulted from un-
balanced inheritance of a balanced familial rearrange-
ment.
In the present patient, a duplication of segment
11p12→13 was found. A duplication of the same seg-
ment was described before by Lavedan et al. [1989].
However, cytogenetically that duplication seemed to be
somewhat different. Both patients had variable eye ab-
Fig. 1. Face of the proposita at 5 months. Note the mild midface hypo-
plasia, small and deep-set eyes, strabismus, broad nasal bridge, and small
mouth.
normalities and borderline developmental delay, with-
out significant malformations or minor anomalies. The
most important clinical data of the 11 reported cases
with partial or complete trisomy of chromosome 11p,
including 11p13, are summarized in Table I. Six pa-
tients were stillborn or died within the first year of life.
In most of the families, several miscarriages and still-
born infants were reported. Mental retardation was
present in all patients and varied from borderline to
severe. Frequently reported clinical findings were
growth retardation, hypertelorism, flat or broad nasal
bridge, cleft lip or palate, and mild acral defects. Inter-
nal abnormalities were infrequent and consisted
mainly of cardiac malformations (aortic coarctation, in-
teratrial septal aneurysm, atresia of the left ventricle,
and ventricular septal defect), intestinal malrotation,
and cryptorchidism.
Ophthalmological findings in the patients were vari-
able and comprised abnormal visual acuity, abnormal
eye movement, microphthalmia, and abnormalities of
the conjunctiva, choroidea, retina, and macula (Table
I). It should be noted that in most patients, only limited
ophthalmological investigations were reported, sug-
gesting that the data on eye involvement may be in-
complete. On the other hand, similar variable eye ab-
normalities, ranging from an almost normal external
appearance to severe microphthalmia, were caused by
the introduction of additional copies of the PAX6 gene
into mice. These PAX6-overexpressing mice also had
microcornea, a flat and irregular iris, and retinal ab-
normalities, with complete absence of the photorecep-
tor layer in one case [Schedl et al., 1996]. There was a
five- to sixfold increase of PAX6 expression levels in the
developing eye of the mice [Schedl et al., 1996] which
 PAX6 Gene Dosage Effect in Humans 269

TABLE I. Summary of the Most Frequent Clinical Findings in 11 Patients With a Partial Duplication of 11p, Including 11p13*

Trisomic segment 11pa 11p11→14b 11p12→terc 11p12→14d,e 11p13→14f 11p12-13g,present case Total n 4 11
General
Growth retardation 3 1 1 1 1 7
Hypo/hypertonia 2 1 1 1 5
Stillbirth/early dead 4 1 1 6
Soft, loose skin 1 1 2
Craniofacial
Abnormal head shapeh 2 2
Prominent forehead 2 1 1 4
Flat supraorbital ridges 1 1 2
Epicanthus 1 1 1 3
Hypertelorism 3 1 2 6
Downslanted palpebral fissures 1 1 2
Small palpebral fissures 1 1 1 3
Flat/broad nasal bridge 3 2 1 6
Abnormal/low-set ears 2 1 1 1 5
Cleft lip/palate 4 1 1 6
Extremities
Overriding toes 2 1 3
Clinodactyly 1 1 1 3
Absent/hypoplastic thumbs 1 1
Joint hypermobility 1 1 1 3
Dermatoglyphic abnormalities 3 1 1 5
Internal
Cardiac abnormalitiesi 1 1 2 4
Herniaj 3 3
Omphalocele 2 2
Urological abnormalitiesk 1 1
Intestinal malrotation 3 1 4
Genital abnormalitiesl 2 2
Cryptorchidism 3 3
Opthalmological
Strabismus 2 1 3
Nystagmus 1 1 1 1 1 5
Abnormal eye movement 1 1
Microphthalmia 1 Marginal 2
Enophthalmia 1 1
Myopia 1 1
Hypermetropia 1 1
Exotropia 1 1
Eccentric fixation 1 1
Eccentric pupils 1 1
Conjunctival teleangiectasia 1 1
Brushfield spots 1 1 2
Abnormal choroidea 1 1
Abnormal macula 1 1
Retinal detachment 1 1
ERG abnormalities (rod) 1 1
*Number of patients in which clinical findings were present are indicated. Otherwise, clinical findings were absent or not reported.
a
Falk et al., 1973; Fryns et al., 1981, 1985; Ogur et al., 1988; Palmer et al., 1976.
b
Strobel et al., 1980.
c
Aleck et al., 1985.
d
Palutke et al., 1980.
e
Sanchez et al., 1974.
f
Speleman et al., 1991.
g
Lavedan et al., 1989.
h
Triangular, dolichocephalic.
i
Aortic coarctation, interatrial septal aneurysm, atresia left ventricle, ventricular septal defect.
j
Umbilical, diaphragmatical, and inguinal.
k
Urethral stenosis and hydronephrosis.
l
Hypospadia, micropenia.

may be of significance compared to the 50% increase in
humans with (partial) duplication of 11p. Although it is
not yet possible to distinguish a clear pattern, these
findings suggest a detrimental effect of extra copies of
PAX6 on eye development in mice and humans.
Developmental analysis in the mouse shows that in
addition to retinal, iris, lens, and surface ectoderm ex-
pression, PAX6 is also expressed in discrete regions of
the forebrain, hindbrain, the neural tube, the pituitary,
and the nasal epithelium [Walther and Gruss, 1991].
Homozygous loss of PAX6 function in mice and in a
single human case is associated with specific central
nervous system defects (expansion of the germinal epi-
thelium, polymicrogyria due to paucity of differenti-
270 Aalfs et al.
Fig. 2. Ophthalmological examination of the proposita at 15 months.
The iris stroma was hypoplastic and showed translucency, especially in the
peripheral region (A, right eye). The lenses were clear, the fundus was
slightly pigmented, and the optic discs were centrally excavated (B, C).
There was an atrophic crescent on the temporal side of both discs and in
the right eye (B). Three distinct areas of choroidal atrophy were present.
The macula area was normal, as were the retinal vessels and peripheral
retina.
Fig. 3. G-banded prometaphase chromosomes from peripheral blood
lymphocytes, showing extra chromosomal material in the short arm of
chromosome 11.
ated neuronal cells in the cortex and heterotopic glia in
the cortex and meninges), suggesting disturbed migra-
tion and differentiation of neuronal precursor cells
[Glaser et al., 1994; Schmahl et al., 1993]. In contrast,
the developmental delay in the present patient and in
the patient described by Lavedan et al. [1989] is very
mild. As far as the role of PAX6 is concerned, this is
Fig. 4. A: Probe 591/1 (detected in green) hybridized to metaphase chro-
mosomes. One chromosome showed two signals. B: Probe AO4160 showing
one signal on the homologous chromosomes. C: Probes 458 (red) and
65-6/13 hybridized to interphase nuclei. D: The order of colors of 458 (red)
and 591/1 (green) demonstrated a tandem duplication rather than an in-
verted duplication.
 PAX6 Gene Dosage Effect in Humans 271

TABLE II. Summary of the Results of FISH on Metaphase Falk RE, Carrel, RE, Valente M, Crandall BF, Sparkes S (1973): Partial
Chromosomes and Interphase Nuclei* Trisomy of chromosome 11: a case report. Am J Ment Defic 77:383–388.
Fantes JA, Oghemne K, Boyle S, Danes S, Fletcher JM, Bruford EA, Wil-
Interval Cosmid Probe Result liamson K, Seawright A, Schedl A, Hanson I, Zehetner G, Bhogal R,
Lerach H, Gregory S, Williams J, Little PFR, Sellar GC, Hoovers J,
D08153 Rapsin +/+
Mannens M, Weissenbach J, Junien C, van Heyningen V, Bickmore
c65-6/13 D11S104 +/+ WA (1995): A high-resolution integrated physical, cytogenetic, and ge-
cCI11-464 D11S676 +/++ netic map of human chromosome 11: Distal p13 to proximal p15.1.
cCI11-468 D11S582 +/++ Genomics 25:447–461.
I c65-6/6 D11S102 +/++ Fryns JP, Haspeslagh M, Goddeeris P, Van Aerde J, Eggermont E, Van den
III cCI11-458 D11S672 +/++ Berghe H (1981): Balanced and unbalanced pericentric inversion of
V B2.1 WT1 +/++ chromosome 11. Ann Genet 24:182–183.
VI p60 p60 +/++ Fryns JP, Kleczkowska A, Vandenberghe K, Moerman F, Van den Berghe
VII FAT5 PAX6 +/++ H (1985): Cystic hygroma and hydrops fetalis in dup(1-1p) syndrome.
IX 591/1 D11S995 +/++ Am J Med Genet 22:287–289.
X AO4160 D11S317 +/+ Glaser T, Jepeal L, Edwards JG, Young SR, Favor J, Maas RL (1994):
EO8153 +/+ PAX6 gene dosage effect in a family with congenital cataracts, aniridia,
XI j10 +/+ anophthalmia and central nervous system defects. Nat Genet 7:463–
XII EO499 FSH +/+ 471.
XIII F1148 +/+ Hanson IM, van Heyningen V (1995): PAX6: More than meets the eye.
XIX SRL7d7 D11S865 +/+ Trends Genet II:268–272.
*Breakpoints were determined by the presence of one signal of a probe on Hill RE, Favor J, Hogan BLM, Ton CCT, Saunders GF, Hanson IM, Prosser
each chromosome 11 (+/+) or two signals of a probe on one of the chromo- J, Jordan T, Hashie ND, van Heyningen V. (1991): Mouse small eye
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