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Nance-Horan Syndrome

The information in NORD’s Rare Disease Database is for educational purposes only. It should never be used for diagnostic or treatment purposes. If you have questions regarding a medical condition, always seek the advice of your physician or other qualified health professional. NORD’s reports provide a brief overview of rare diseases. For more specific information, we encourage you to contact your personal physician or the agencies listed as “Resources” on this report.

Copyright 1996, 1997, 2001, 2011, 2014

NORD is very grateful to Annick Toutain, MD, PhD, Service of Genetics Center, Hospital-University of Tours, Francois Rabelais University, for assistance in the preparation of this report.

Synonyms of Nance-Horan Syndrome

Disorder Subdivisions

General Discussion

Nance-Horan syndrome is a rare genetic disorder that may be evident at birth (congenital). It is primarily characterized by abnormalities of the teeth and clouding of the lens of the eyes (congenital cataracts), resulting in poor vision. Additional eye (ocular) abnormalities are also often present, such as unusual smallness of the front, clear portion of the eye through which light passes (microcornea) and involuntary, rapid, rhythmic eye movements (nystagmus). In some cases, the disorder may also be associated with additional physical abnormalities and/or intellectual impairment. The range and severity of symptoms may vary greatly from one person to another, including among affected members of the same family.
Nance-Horan syndrome is inherited as an X-linked trait that it is usually fully expressed in males only. However, females who carry a single copy of the disease gene (heterozygotes) may manifest some of the symptoms and findings associated with the disorder. These may include microcornea and/or clouding of the lens of the eyes (posterior sutural cataract). Symptoms are less severe than those of affected males, potentially causing only slightly decreased clearness or clarity of vision (visual acuity). In some cases, abnormalities of the teeth may also be present. Intellectual impairment rarely occurs in females.

Symptoms

In affected males, the primary physical characteristic associated with Nance-Horan syndrome is the presence of dense clouding (opacities) of the lens of both eyes at birth (congenital bilateral nuclear cataracts). The lens of an eye is the small transparent flattened and elongated ball located behind the iris through which light passes. The light focuses on the retina, the thin nerve-rich membrane that lining the back of the eye. The retina converts the light into nerve impulses and relays the information along the optic nerve to the brain. Cataracts affect both eyes (bilateral) and usually result in blurred vision and severely decreased clearness or clarity of vision (visual acuity). Vision loss can potentially be profound.

Males with Nance-Horan syndrome may have additional eye abnormalities. The front (anterior), clear portion of the eye through which light passes (cornea) may be unusually small (microcornea). In addition, affected males with poor vision may have recurrent, involuntary, "to-and-fro" movements of the eyes (pendular nystagmus) and/or misalignment of the eyes (strabismus). In some cases, the entire eye may be abnormally small (microphthalmia) and/or the upper eyelid may droop (ptosis).

Males with Nance-Horan syndrome may also have several dental abnormalities such as unusually shaped, extra (supernumerary) teeth, absence of some teeth (dental agenesis), impacted teeth or unusually wide spaces (diastema) between some of the teeth. Front teeth (incisors) are tapered and "screwdriver-shaped" or are similar in appearance to a tooth abnormality often associated with congenital syphilis (i.e., Hutchinson's teeth). Posterior teeth may be conical, rounded, cylindrical or with extra cusps (small bumps at the surface of the molar teeth). In some cases, affected males may have an extra (supernumerary), centrally located front tooth in the upper jaw (mesiodens). The tooth may be "cone-shaped" with an abnormally short root Such supernumerary incisors may prevent or disrupt the normal eruption of permanent incisors in some cases. Both the baby (deciduous) and permanent teeth are involved.

In many males with Nance-Horan syndrome, other physical findings may also occur. Distinctive facial features may be present, but may be subtle. The ears may be flared forward (anteverted) and unusually prominent, with folded lobes. Affected males may have a large, prominent nose with a high, narrow nasal bridge; a narrow prominent jaw (prognathism); and a long sometimes narrow face.

Some males with Nance-Horan syndrome may also experience delays in the acquisition of skills requiring the coordination of muscular and mental activity (psychomotor retardation). In addition, some reports suggest that approximately 20 to 30 percent of affected males may have varying levels of intellectual dysfunction. Intellectual dysfunction is usually mild or moderate, but in some cases can be severe.

As mentioned above, females who carry a single copy of the disease gene for Nance-Horan syndrome (heterozygotes) may develop some symptoms of the disorder. Such symptoms are usually milder and more variable than those associated with the fully expressed disorder. Affected females may have abnormally small corneas (microcornea) and/or Y-shaped clouding (opacities) in the back portion of the lens of the eyes at birth (congenital posterior sutural cataracts). Vision may be normal, or there may be slightly decreased clearness or clarity of vision (visual acuity). Without appropriate treatment, posterior sutural cataracts may progress to total clouding of the lens of the eyes (total cataracts) later in life. Heterozygous females often have some dental abnormalities, such as abnormally-shaped front teeth (incisors) and/or unusually wide spaces (irregular diastema) between some of the teeth. Affected females usually do not develop intellectual impairment.

Causes

Nance-Horan syndrome is caused by mutations of the NHS gene, which is located on the X chromosome. Nance-Horan syndrome is inherited as an X-linked trait. Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother.

X-linked disorders are conditions that result from changes (mutations) of a gene on an X chromosome. Females have two X chromosomes, but males have one X chromosome and one Y chromosome. In females, disease traits resulting from the abnormal copy of a gene on one X chromosome can be "masked" by the normal copy of the gene on the other X chromosome. (For more, see below.) In the opposite, since males only have one X chromosome, if they inherit an abnormal copy of a gene for a disease present on the X, it will likely be fully expressed. Men with X-linked disorders transmit the gene to all their daughters, who are carriers, but never to their sons. Women who are carriers of an X-linked disorder have a 50 percent risk of transmitting the carrier condition to their daughters and a 50 percent risk of transmitting the disease to their sons.

As mentioned above, in females who carry a copy of a disease gene for an X-linked trait, disease traits on the X chromosome may essentially be "masked" by the normal gene on the other X chromosome. More specifically, because only one functioning X chromosome is required in males and females, one of the X chromosomes in each cell of a female is essentially "turned off", usually in a random pattern (random X chromosome inactivation). Therefore, if the X chromosome with the gene mutation is activated in some cells, female carriers may manifest certain, typically more variable or mild features of the disorder as previously discussed (see Symptoms section above).

Investigators have determined that Nance-Horan syndrome is caused by mutations of the NHS gene. The function of this gene is not fully understood. The gene has been mapped to the short arm (p) of chromosome X (Xp22.31-p22.13). Chromosomes are found in the nucleus of all body cells. They carry the genetic characteristics of each individual. Pairs of human chromosomes are numbered from 1 through 22, with an unequal 23rd pair of X and Y chromosomes for males and two X chromosomes for females. Each chromosome has a short arm designated as "p" and a long arm identified by the letter "q." Chromosomes are further subdivided into bands that are numbered. Therefore, "Xp22.13" refers to band 22.13 on the short arm of chromosome X.

Affected Populations

As discussed above, Nance-Horan syndrome is usually fully expressed in males only, although females who carry a single copy of the disease gene (heterozygotes) may develop certain features. The disorder is present at birth (congenital). Nance-Horan syndrome was described in 1974 by two research teams independent of each other. Fewer than 50 families (kindreds) have been described in the medical literature. The exact incidence of the disorder is unknown. Researchers believe that cases may go unrecognized or misdiagnosed, making it difficult to determine the true frequency of Nance-Horan syndrome in the general population.

Related Disorders

Symptoms of the following disorders may be similar to those of Nance-Horan syndrome. Comparisons may be useful for a differential diagnosis:

There are several other rare inherited disorders in which clouding of the lens of the eyes at or shortly after birth (congenital or postnatal cataracts) occurs in association with other abnormalities of the eye. In some cases, the front (anterior), clear portion of the eye through which light passes (cornea) may be unusually small and/or the entire eye may be smaller than normal (microphthalmia). In addition, affected individuals may exhibit rapid, involuntary movements of the eyes (nystagmus); nearsightedness (myopia); misaligned eyes (strabismus); and/or other abnormalities of the eyes. Visual impairment may range from slight to severe, depending upon the extent of cataracts and/or any additional eye abnormalities that are present. These rare cataract disorders are typically isolated and/or may be inherited as autosomal dominant, autosomal recessive, and/or X-linked genetic traits, depending upon the disorder in question. Such disorders include isolated microphthalmia with cataract; cataract-microcornea syndrome; X-linked congenital cataract (total congenital cataract with posterior sutural opacities in heterozygotes; and X-linked congenital cataract with microcornea. The latter two disorders are caused by mutations in the same gene that causes Nance-Horan syndrome (allelic disorders). Some researchers believe that these three disorders represent different expressions of one disorder.

Lenz microphthalmia syndrome is an extremely rare inherited disorder characterized by abnormal smallness of one or both eyes (unilateral or bilateral microphthalmia) and/or droopy eyelids (blepharoptosis), resulting in visual impairment. In rare cases, affected infants may exhibit complete absence or rudimentary (vestigial) portions of the eyes (anophthalmia). Most affected infants also exhibit developmental retardation, ranging from mild to severe, as well as mental retardation. Additional physical abnormalities associated with this disorder may include an unusually small head (microcephaly); teeth that are widely spaced or abnormally crowded; ears that flare forward (anteverted) and/or are underdeveloped (hypoplastic); and/or malformations of the fingers and/or toes (digits). Some affected individuals may also exhibit incomplete closure of the roof of the mouth (cleft palate); a vertical groove in the upper lip (cleft lip); a sideways and front-to-back curvature of the spine (kyphoscoliosis); and/or abnormalities of the reproductive and urinary (genitourinary) tract, such as failure of the testes to descend into the scrotum in males (cryptorchidism) and/or underdevelopment (hypoplasia) or absence of a kidney (renal agenesis). Lenz microphthalmia syndrome, which is inherited as an X-linked genetic trait, is fully expressed in males only. However, females who carry one copy of the disease gene (heterozygotes) may exhibit some of the signs associated with the disorder, such as an abnormally small head (microcephaly) and/or malformations of the fingers and/or toes. (For more information on this disorder, choose "Lenz Microphthalmia" as your search term in the Rare Disease Database.)

Standard Therapies

Diagnosis
Nance-Horan syndrome may be diagnosed based upon a thorough clinical evaluation, detection of characteristic physical findings such as congenital cataracts and dental abnormalities, and specialized testing, including the use of an illuminated microscope to examine the interior of the eyes (slit-lamp examination) and dental x-ray series. Molecular genetic testing for the NHS gene is available to confirm the diagnosis.

Treatment
The treatment of Nance-Horan syndrome is directed toward the specific symptoms that are apparent in each individual. Treatment may require the coordinated efforts of a team of specialists, such as pediatricians; physicians who diagnose and treat diseases of the eye (ophthalmologists); dental specialists who diagnose, prevent, and/or correct misalignment (malocclusion) and other abnormalities of the teeth (orthodontists); and other health care professionals.

A variety of methods may be used to treat, prevent, and/or correct eye defects associated with Nance-Horan syndrome, depending upon the specific combination of abnormalities present, their severity, and/or other factors. In affected males with cataracts, surgery may be recommended to remove the cataracts and, in some cases, to implant artificial lenses. Significant vision loss may still occur despite surgical removal of cataracts. In addition, corrective glasses, contact lenses, and/or other measures may be used to help improve vision.

Approximately 50 percent of males with Nance-Horan syndrome develop glaucoma, which results from cataract surgery during infancy. Glaucoma is a condition marked by a rise in the pressure within the eyeball preventing the normal drainage of fluid from the eye and potentially causing characteristic damage to the optic nerve, which relays nerve impulses from the retina to the brain. Glaucoma may be treated medically or surgically.

Carrier females and at-risk females should receive regular examinations from an ophthalmologist to ensure early detection of eye abnormalities potentially associated with the disorder. Infrequently, cataract surgery may be recommended to improve or preserve visual acuity.

In affected individuals with extra front teeth (supernumerary incisors), surgery may be advised to remove the additional incisors. Braces, dental surgery, and/or other corrective procedures may also be undertaken to correct other dental abnormalities, such as unusually wide spaces (diastema) between some of the teeth.

Early intervention is important in ensuring that affected children reach their potential. Special services that may be beneficial may include special remedial education and other medical, social, and/or vocational services. Affected individuals may need to attend a school for the visually impaired.

Genetic counseling will be of benefit for affected individuals, at-risk females, and their families. Family members of affected individuals should also receive regular clinical evaluations to detect any symptoms and physical characteristics that may be potentially associated with Nance-Horan syndrome or heterozygosity for the disorder.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com

For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/

Organizations related to Nance-Horan Syndrome

(Please note that some of these organizations may provide information concerning certain conditions potentially associated with this disorder [e.g., visual impairment, dental abnormalities, mental retardation, etc.].)

References

TEXTBOOKS
Toutain A. Nance-Horan syndrome.NORD Guide to Rare Disorders.Lippincott Williams & Wilkins. Philadelphia, PA. 2003:654-655.

Gorlin RJ, et al, eds. Syndromes of the Head and Neck. 4th ed. New York, NY: Oxford University Press; 2001:1108-1109.

JOURNAL ARTICLES
Ding X, Patel M, Herzlich AA, Sieving PC, Chan CC. Ophthalmic pathology of Nance-Horan syndrome: case report and review of the literature. Ophthalmic Genet. 2009;30:127-135.

Coccia M, Brooks SP, Webb TR, et al. X-linked cataract and Nance-Horan syndrome are allelic disorders. Hum Mol Genet. 2009;18:2643-2655.

Florijn RJ, Loves W, Maillette de Buy Wenninger-Prick LJ, et al.New mutations in the NHS gene in Nance-Horan syndrome families from the Netherlands.Eur J Med Genet. 2006;14:986-990.

Brooks SP, Ebenezer ND, Poopalasundaram S, et al. Identification of the gene for Nance-Horan (NHS).J Med Genet. 2004;41:768-771.

Burdon KP, McKay JD, Sale MM, et al. Mutations in a novel gene, NHS, cause the pleiotrophic effects of Nance-Horan syndrome including severe congenital cataract, dental abnormalities, and mental retardation. Am J Hum Genet. 2003;73:1120-1130.

Toutain A, Dessay B, Ferrante MI, et al. Refinement of the NHS locus on chromosome Xp22.13 and analysis of five candidate genes. Eur J Hum Genet.2002;10:516-520.

Toutain A, Ronce N, Dessay B, et al. Nance-Horan syndrome: linkage analysis in 4 families refines localization in Xp22.31-p22.13 region. Hum Genet. 1997;99:256-61.

Stambolian D, Lewis RA, Buetow K, Bond A, Nussbaum R. Nance-Horan syndrome: localization within the region Xp21.1-Xp22.3 by linkage analysis. Am J Hum Genet. 1990;47:13-19.

Zhu D, Alcorn DM, Antonarakis SE, et al. Assignment of the Nance-Horan syndrome to the distal short arm of the X chromosome. Hum Genet. 1990;86:54-58.

Lewis RA, Nussbaum RL, Stambolian D. Mapping X-linked ophthalmic diseases. IV. Provisional assignment of the locus for X-linked congenital cataracts and microcornea (the Nance-Horan syndrome) to Xp22.2-p22.3. Ophthalmology. 1990;97:110-20, Discussion 120-21.

Lewis RA. Mapping the gene for X-linked cataracts and microcornea with facial, dental, and skeletal features to Xp22: an appraisal of the Nance-Horan syndrome. Trans Am Ophthalmol Soc. 1989;87:658-728.

Bixler D, Higgins M, Hartsfield J Jr. The Nance-Horan syndrome: a rare X-linked ocular-dental trait with expression in heterozygous females. Clin Genet. 1984;26:30-35.

Horan MB, Billson FA.X-linked cataract and Hutchinsonian teeth.AustPaediat J. 1974;10:98-102.

Nance WE, Warburg M, Bixler D, Helveston EM.Congenital X-linked cataract, dental anomalies and brachymetacarpalia. Birth Defects Orig Art Ser. 1974;10:285-91.

INTERNET
Toutain A. Nance-Horan syndrome.Orphanet, September 2007. Available at: http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=EN&Expert=627.0 Accessed Feb 11, 2014.

Report last updated: 2014/02/12 00:00:00 GMT+0