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Leber Hereditary Optic Neuropathy (LHON), also known as Leber Optic Atrophy (LOA), was first described in 1871 as a sudden loss of vision in young men with a family history of blindness. It is the most common of the hereditary Optic Atrophies.
Symptoms and Signs of LHON
The disease causes a loss of central vision within two to eight weeks, usually affects both eyes, may cause eye pain or discomfort at first, and may cause neurological symptoms such as numbness and tingling. Ophthalmologists detect signs of optic nerve degeneration such as visual field defects, blood vessel changes around the optic disc, optic disc pallor, pupil reflex abnormalities, and color vision abnormalities. Recent work suggests that abnormalities only found on examination usually preceed visual symptoms.[Yu-Wai-Man & Chinnery 2008] [OMIM] [Kerrison & Newman 1997][Sadun et al 2006]
In 1988 researchers discovered that LHON is one of a group of mitochondrial diseases, genetic diseases that are inherited only through the mother. [Wallace et al 1988] Mitochondria are the bodies within cells where energy needed for the activities of the cell is produced from oxygen. There are now some twenty different genes known to take part in the development of LHON. Three particular mutations account for 85% to 90% of the cases of LHON. However, the mitochondial mutation is clearly not the only genetic factor involved in the disease, as not every carrier is affected and men are at higher risk than women.
The factors that render mitochondria in optic nerve cells unable to produce energy thereby producing cell death, are largely unknown. One hypothesis is that cell death is actually programmed, and is the result of a random distribution of defective mitochondrial DNA during the normal mitotic division and ageing process of cells. [Melov et al 1997]
The discovery that LHON is a mitochondrial disease has led to a diagnostic molecular genetic blood test. Testing for mutations using polymerase chain reaction techniques is available in a few centers around the world. [Yu-Wai-Man & Chinnery 2008] The test is 100% accurate for LHON when visual loss has already occurred. Family members of someone with LHON who test positive may be at risk for LHON. It is important for family members to be tested because changes in lifestyle and diet may help prevent the onset of LHON. IFOND may be able to help with names of nearby specialists in optic nerve disease for those who have had a sudden visual loss that cannot be corrected by glasses and the diagnosis is unknown.
LHON mutations are prevalent in ~1 in 8,500 individuals in the general population.[Man et al 2003] Current research reveals that while LHON occurs 80% of the time in young men in their twenties, it also occurs in men, and in women, of all ages. In one study the onset of LHON was found to have occurred in men and women as young as six and as old as sixty two. Other research finds that LHON may occur in someone who has no family history of LHON or blindness. Expression of the gene varies with the mitochondrial mutation and the family but in general the chances of the eyes of female carriers remaining healthy are over 85% and of males over 50%.
Risk Factors for Onset Of Blindness
Genetic Markers Present - A simple painless test using hair, cheek, and blood cells can be performed to genetically type mitochondria. If there is a family history of sudden onset of blindness, whatever age, it is wise to check this out as the understanding of this disease process is relatively new as is the ability to test and classify the genes. The tests are only performed in certain centres around the world, and samples may have to be sent some distance.
Genotype - There are many different areas within the mitochondria that may be affected. The area, or site on the mitochondria DNA that contains the mutation is expressed as a number. The particular mitochondrial mutation may affect severity and likelihood of blindness or possible recovery. Up to 80% of the mutations documented are 11778, 3460, and 14484. However research is showing that there are other mutations. [OMIM] Nuclear chromosomal X-linked alleles. [Hudson et al 2005] Other genetic patterns called mitochondrial DNA-haplogroup background may influence the disorder.[Hudson et al 2007a]
Mature Males Predominate - Males with the LHON mitochondria and are between the ages of 26 to 45 you may be more at risk of developing the disease.
Homoplasmy - Of those that have affected mitochondria, some have a greater ratio of "affected" to "normal" mitochondria. This is usually expressed as a percentage. For instance, if 8% normal mitochondria were detected amongst 92% affected cells tested the term is "heteroplasmic". If all measured mitochondria are affected you may be more at risk due to this "homoplasmic" state. But, many people with documented homoplasmy still have normal vision.[Kerrison & Newman 1997]
Toxic substances - ingested, inhaled or absorbed through the skin, have been shown to cause neurological and optic blindness and it is suggested that those people with genetic or aquired deficiencies of the mitochondria may be more susceptible to small amounts of these sorts of substances.[Sadun et al 2003][Sadun 1998] More work is needed to determine whether mitochondrial deficiency results in increased susceptibility. The toxic substances shown to cause blindness include:
For those at risk a double check with the doctor and pharmacist is highly recommended before taking a course of drugs for any reason.
Possible Protective Factors
Unfortunately, at present there is no certain cure for LHON. Though early treatment [Klopstock et al 2011] [Carelli et al 2011] may be effective in preserving some vision in some cases. For now prevention, with avoidance of possible toxins, and judicious use of antioxidants when toxins are unavoidable, is the cornerstone of hope. In case of an acute onset of blindness in a recognised family pedigree of Leber's, it is important if at all possible, to be monitored by an ophthalmologist. Hopeful experimental protocols are in progress.
Protective genes. As there are many more cases of male onset of blindness than female, it is postulated that there is some protective factor in the female body. X chromosome markers have been found which may influence disease outcome in carriers.[Hudson et al 2005] It is possible that sex hormone receptors such as androgen receptor may play a role.[Hudson et al 2007b] Mitochondrial halpogroup is known to play a role in penetrance in some mutations.[Hudson et al 2007a] A search for protective genes on other chromosomal and mitochondrial DNA continues.
Hormonal Factors. Female hormones, progesterone and oestrogen, are currently suspected to play a role in protecting women carriers. This is based on the female protective bias, the slight increase in incidence in post menopausal women, anecdotal reports of disease reversal after hormone replacement therapy and in vitro studies of cybrid cell lines.[Giordano et al 2011] The fact that females' exercise metabolism tends to be more based on fat metabolism than males thus relatively mitochondrial sparing could be relevant. [Blaak 2001] [Power 2007]Clinical studies of oestrogen and other mitochondrial sparing substances are currently being planned. Progesterone has proven neuroprotective benefits in central nervous system injury. [Deutsch et al 2013] In the mean time neuro-ophthalmologist clinicians are suggesting oestrogen hormone replacement be considered for their menopausal LHON carrier patients.
Clinical trials of idebenone [Klopstock et al 2011] [Carelli et al 2011] have shown modest effectiveness in approximately half of cases. Early and prolonged therapy offered most chance of partial recovery. Previously there was some inconsistent ancedotal evidence for this ubiquinone [coenzyme Q10]-like derivative, mildly altering progress or spontaneous recovery in some mutations in some cases. [Mashima et al 2000] [Barnils et al 2007] It is conjectured that inadequate amounts of the substance actually reaching the mitochondria was cause for these early experimental treatment failures.
Various agents and medications have been proposed, not just for LHON but for various other optic neuropathies. IFOND does not recommend any of the agents listed below. We bring you this information for you to stay current on the status of the proposed and somewhat controversial disease modifying therapies. However, the IFOND Scientific Board is intensely involved in research to find potential treatment methods.
Reports of cure with drugs in isolated LHON cases may be spontaneous recoveries which are known to happen in some mutations more than others. Or the intervention may have meant the difference for that individual. The reasons for these "cures" remain a mystery.
Though there is conflicting data about their direct relationship to LHON, [Tsao et al 1999][Kerrison et al 2000][Sadun et al 2003] it is generally regarded as prudent to avoid drinking alcohol and smoking tobacco. Both of these are known to aggravate or cause other eye diseases as well. They may also interact with other environmental or occupational toxins in a harmful way.
Proposed therapy research
Wallace suggests the failure so far of some single agent metabolic approaches in treating mitochondrial disease points to a systems approach. He proposes the revival of the high fat, low carbohydrate "ketogenic diet" long used by neurologists for treating intractable epilepsy and arguably the normal diet for many peoples for thousands of years. This model therapy effects a profound change from carbohydrate metabolism which changes multiple pathways and encourages mitochondrial preservation.[Wallace 2010] There are anectodal reports of successful treatment in mitochondrial disease using this approach[Kang 2006] [Kang 2007] [Ahola-Erkkilä 2010] [Zhao 2012] The hypothesis is consistent with the observed gender differences in LHON disease expression and increased post menopausal incidence as premenopausal females tend to use mitochondrial sparing fat metabolism in exercise more than males. [Abildgaard 2013][Blaak 2001] [Power 2007] Interesting epidemiological observations show a low incidence of primary open angle glaucoma in Inuit and Asians. [Arkell 1987] [Congdon 1992] [Bourne 2001] These groups traditionally ate high fat diets or intermittently starved and exercised regularly to survive.[Blanchet 2002] Some Inuit are currently undergoing a social / cultural / dietary experiment probably to the detriment to their general health and possibly to their eyes. [Sheehy 2013] Chinese rates of open angle glaucoma are rising with urbanised lifestyles. [Wang 2011] Clinical prospective studies on ketogenic diets and exercise therapy for optic nerve disease are called for. [Risner 2009][Zarnowski 2012]
Antioxidants are a key to providing stability to the nerve cell and decreasing the likelihood of oxidative damage caused by free radicals released when cells are destroyed by chemical toxins. Antioxidants can be classified according to drug type and include Vitamins and natural plant extracts, for example, Vitamin E, Co-enzyme Q, Vitamin C, Vitamin A, Ginkgo biloba, curcumin. [Ritch 2007] [Clinical Trial Curcurmin 2007]Antioxidants are also part of the body's normal makeup and possibly could be induced to perform better. One proposal in this regard is the use of near infrared light which has had some success in wound and ulcer healing.[Wisconsin trial]
Alpha-tocotrienol-quinone, a Vitamin E metabolite, has had some success in small open label trials in reversing early onset vision loss. Based on this, FDA approved trials are scheduled to begin in July 2011. [Shrader et al 2011]
Various agents are being considered for optic nerve protection. One line of thinking separates axonal from cell body causes of nerve degeneration. It is uncertain how this applies to LHON. [Levin 2007] Brimonidine is one agent thought to have neuroprotective qualities which has been trialed in a small number of early onset LHON cases with mixed results.[Newman et al 2005]
Laboratory research continues on virus vector gene therapy and stem cell therapy. [Qi et al 2007] These lines of treatment have been used experimentally in people with other nerve injuries and diseases, but not in LHON.
The sparse negative anectodal evidence of Hyperbaric Oxygen Therapy [HBO] treatment specifically in LHON is not encouraging. This is not currently a line of active research in LHON. HBO has been suggested as a treatment by delivering increased levels of oxygen to the affected nerve cell during its "starvation" period, or period of onset of blindness. A counter argument is that too much oxygen may be toxic in the context of poor cell antioxidant functioning. Oxygen toxicity to the eye is a known problem in premature babies on oxygen. There has been some success, however, using HBO with with other nerve diseases.
Three person in vitro fertilisation is a proof of concept research technique for preventing mitochondrial disease in developing human fetuses. So far, viable macaque monkeys have been produced. The United Kingdom has approved experimental use of the technique in humans. [Craven et al 2010][The Guardian 20130628]
Research in LHON is ongoing and of prime importance, as this is a "model" disease. The data gathered may be of importance not only for LHON affected families but for millions of others affected by many other diseases.
For example, the crucial cellular damage which leads to nerve cell death and blindness in Leber's Hereditary Optic Neuropathy is similar to nerve cell damage that occurs in Parkinson's disease, Alzheimer's disease and glaucoma. These common, slowly progressing neurodegenerative diseases affect millions in the United States alone. The time span of the disease process in LHON is more rapid, two to eight weeks. Though new research has found tests of LHON disease progress prior to blindness. Finding the reason for this intriguing difference in timing may give clues to the eventual cures of these and other eye and nervous system diseases.
Why do some children who have inherited mitochondrial mutations responsible for LHON become blind while their siblings, born with the same mutations do not develop LHON? It is clear that genetic inherited mitochondrial mutations are not sufficient alone to explain blindness. What other factors may play a role?
Do the risk factors now known to cause blindness in some cases, actually stimulate the development of LHON? If so, how? Are there other risk factors? It seems clear from current knowledge that environmental risk factors play an important role in the onset of LHON but much more needs to be learned about the known potential risk factors, and the possible existence of other risk factors.
These questions, concerning the interplay of genetics and environment are important to work going on now to find ways to prevent the onset of LHON,and may well be of importance to furthering research in other optic nerve diseases, and neurodegenerative diseases.
The Guardian. 2013 June 28. Three-person IVF: UK government backs mitochondrial transfer
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Updated 29 Sept 2013. Bryan Cebuliak
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