Norrie disease is an inherited eye disorder that leads to blindness in male infants at birth or soon after birth. It causes abnormal development of the retina, the layer of sensory cells that detect light and color, with masses of immature retinal cells accumulating at the back of the eye. As a result, the pupils appear white when light is shone on them, a sign called leukocoria. The irises (colored portions of the eyes) or the entire eyeballs may shrink and deteriorate during the first months of life, and cataracts (cloudiness in the lens of the eye) may eventually develop.

About 30 percent of individuals with Norrie disease develop progressive hearing loss, and 30 to 50 percent of people affected experience developmental delays in motor skills such as sitting up and walking. Other problems may include mild to moderate intellectual disability, often with psychosis, and abnormalities that can affect circulation, breathing, digestion, excretion, or reproduction.

Mutations in the NDP gene cause Norrie disease. The NDP gene provides instructions for making a protein called norrin. Norrin participates in the Wnt cascade, a sequence of steps that affect the way cells and tissues develop. In particular, norrin seems to play a critical role in the specialization of retinal cells for their unique sensory capabilities. It is also involved in the establishment of a blood supply to tissues of the retina and the inner ear, and the development of other body systems.

In order to initiate the Wnt cascade, norrin must bind (attach) to another protein called frizzled-4. Mutations in the norrin protein interfere with its ability to bind to frizzled-4, resulting in the signs and symptoms of Norrie disease.

Normal Function

The NDP gene provides instructions for making a protein called norrin. Norrin participates in chemical signaling pathways that affect the way cells and tissues develop. Studies suggest that norrin may play a role in Wnt signaling, which is important for cell division (proliferation), attachment of cells to one another (adhesion), cell movement (migration), and many other cellular activities.

Norrin is one of many proteins, or ligands, that can attach (bind) to other proteins called frizzled receptors. These receptors are embedded in the outer membranes of cells. Norrin binds with the receptor frizzled-4 (produced from the FZD4 gene), fitting together like a key in a lock. When a ligand binds to a frizzled receptor, it initiates a multi-step process that regulates the activity of certain genes.

The norrin protein and its receptor frizzled-4 participate in developmental processes that are believed to be crucial for normal development of the eye and other body systems. In particular, norrin seems to play critical roles in the specialization of cells in the retina (the thin layer at the back of the eye that senses light and color) and the establishment of a blood supply to the retina and the inner ear.

Health Conditions Related to Genetic Changes

Familial exudative vitreoretinopathy

Several NDP gene mutations have been found to cause the eye disorder familial exudative vitreoretinopathy. These mutations change single protein building blocks (amino acids) in the norrin protein, altering the normal folding of norrin or preventing it from binding to frizzled-4. The defective norrin disrupts chemical signaling in the developing eye, which interferes with the formation of blood vessels at the edges of the retina. The resulting abnormal blood supply to this tissue leads to retinal damage and vision loss in some people with familial exudative vitreoretinopathy.

Norrie disease

More than 115 mutations in the NDP gene have been identified in people with Norrie disease. Norrie disease is an inherited eye disorder that leads to blindness in male infants at birth or soon after birth. NDP gene mutations that cause this condition affect the ability of the norrin protein to bind with frizzled-4, interfering with the specialization of retinal cells for their unique sensory function. As a result, masses of immature retinal cells accumulate in the back of the eyes. Disruption of norrin's role in the establishment of blood vessels supplying the eye eventually causes some of the tissues to break down.

Norrin is also expressed in other systems of the body, and the effects of the disorder can be widespread, including intellectual disability, seizures, behavioral problems, and delayed development. Specific abnormalities and their severity depend on the type and location of the NDP gene mutation. Mutations that delete portions of the NDP gene prevent production of norrin and result in severe problems affecting many body systems in addition to the eyes. Mutations that delete or change single amino acids usually result in less widespread effects.

Other retinal dystrophies

NDP gene mutations may cause other disorders that affect the retina. One mutation is associated with a disorder called Coats disease. This disorder causes leakage of blood vessels in the retina and retinal detachment, a condition in which layers of the retina separate, resulting in vision loss. Persistent hyperplastic primary vitreous (PHPV) is another retinal disorder that may be caused by NDP gene mutations. In persistent hyperplastic primary vitreous, a remnant of a blood vessel found in the eye before birth remains as a fibrous white stalk between the back of the eye and the lens. Persistent hyperplastic primary vitreous can cause vision loss through retinal detachment, cloudiness of the lens (cataract), or increased pressure inside the eye (glaucoma) that can damage the optic nerve.

In addition, NDP gene mutations may influence the course of a retinal disorder that affects some premature infants. Retinopathy of prematurity is a condition in which abnormal blood vessels appear in the retina and can cause retinal detachment. Babies with retinopathy of prematurity may experience improvement of the condition over time, but some NDP gene mutations have been associated with a worsening of the condition.

Other Names for This Gene

• ND
• NDP_HUMAN
• Norrie disease (pseudoglioma)
• norrin

Genomic Location

This condition is inherited in an X-linked recessive pattern. A condition is considered X-linked if the mutated gene that causes the disorder is located on the X chromosome, one of the two sex chromosomes. In males (who have only one X chromosome), one altered copy of the gene in each cell is sufficient to cause the condition. In females (who have two X chromosomes), a mutation must be present in both copies of the gene to cause the disorder. Males are affected by X-linked recessive disorders much more frequently than females. A characteristic of X-linked inheritance is that fathers cannot pass X-linked traits to their sons.

In X-linked recessive inheritance, a female with one altered copy of the gene in each cell is called a carrier. She can pass on the gene, but generally does not experience signs and symptoms of the disorder.

In rare cases, however, carrier females have shown some retinal abnormalities or mild hearing loss associated with Norrie disease. Females with one NDP gene mutation who show features of Norrie disease do so because of a process called X-inactivation. Early in embryonic development in females, one of the two X chromosomes is permanently turned off (inactivated) in somatic cells (cells other than egg and sperm cells). X-inactivation ensures that females, like males, have only one active copy of the X chromosome in each body cell. Usually X-inactivation occurs randomly, so that each X chromosome is active in about half the body's cells. This means that in females with an NDP gene mutation, the X chromosome with an NDP gene mutation is active in about half of cells, and the X chromosome with the normal NDP gene is active in about half. Because X-inactivation leads to some cells that produce functional norrin protein and some cells that do not, females can have some features of Norrie disease.