DIAGNOSIS AND TREATMENT OF AXENFELD-RIEGER SYNDROME
Abstract
Introduction: Axenfeld-Rieger syndrome (ARS) is a rare congenital disorder characterized by anterior segment dysgenesis and diverse systemic anomalies. Mutations in genes such as PITX2 and FOXC1 are most commonly implicated in its pathogenesis. The condition significantly affects vision, primarily due to structural disruption of the visual axis and the high incidence of secondary glaucoma.
Aim of the study: The purpose of this study is to provide an updated overview of Axenfeld-Rieger syndrome, with emphasis on its historical background, genetic mechanisms, clinical manifestations, and current therapeutic strategies.
Research materials and methods: A systematic review of scientific and medical literature was conducted using PubMed and Google Scholar databases.
Conclusions: Genetic testing and comprehensive clinical evaluation are crucial for accurate diagnosis and optimal management of ARS. Due to its multisystem nature, care should be coordinated within a multidisciplinary framework. Early recognition of glaucoma and other systemic manifestations is essential to improve long-term outcomes.
References
Seifi M, Walter MA. Axenfeld-Rieger syndrome. Clin Genet. 2018;93(6):1123-1130. doi:10.1111/cge.13148
Shields MB, Buckley E, Klintworth GK, Thresher R. A Spectrum of Developmental Disorders. Vol 29.
Chang TC, Summers CG, Schimmenti LA, Grajewski AL. Axenfeld-Rieger syndrome: New perspectives. British Journal of Ophthalmology. 2012;96(3):318-322. doi:10.1136/bjophthalmol-2011-300801
Alward WLM. PERSPECTIVE Axenfeld-Rieger Syndrome in the Age of Molecular Genetics.; 2000.
Michels K, Bohnsack BL. Ophthalmological Manifestations of Axenfeld-Rieger Syndrome: Current Perspectives. Clinical Ophthalmology. 2023;17:819-828. doi:10.2147/OPTH.S379853
Philli JC, Bono EA Del, Haines JL, et al. A Second Locus for Rieger Syndrome Maps to Chromosome 13q14. Vol 59.; 1996.
Riise R, Storhaug K, Brøndum‐Nielsen K. Rieger syndrome is associated with PAX6 deletion. Acta Ophthalmol Scand. 2001;79(2):201-203. doi:10.1034/j.1600-0420.2001.079002201.x
Werner W, Kraft S, Callen DF, Bartsch O, Hinkel GK. A small deletion of 16q23.1-->16q24.2 [del(16)(q23.1q24.2).ish del(16)(q23.1q24.2)(D16S395+, D16S348-, P5432+)] in a boy with iris coloboma and minor anomalies. Am J Med Genet. 1997;70(4):371-376.
Tümer Z, Bach-Holm D. Axenfeld-Rieger syndrome and spectrum of PITX2 and FOXC1 mutations. European Journal of Human Genetics. 2009;17(12):1527-1539. doi:10.1038/ejhg.2009.93
Lehmann OJ, Sowden JC, Carlsson P, Jordan T, Bhattacharya SS. Fox’s in development and disease. Trends in Genetics. 2003;19(6):339-344. doi:10.1016/S0168-9525(03)00111-2
Gould DB, Jaafar MS, Addison MK, et al. Phenotypic and molecular assessment of seven patients with 6p25 deletion syndrome: Relevance to ocular dysgenesis and hearing impairment. BMC Med Genet. 2004;5(1):17. doi:10.1186/1471-2350-5-17
Hjalt TA, Semina E V. Current molecular understanding of Axenfeld-Rieger syndrome. Expert Rev Mol Med. 2005;7(25). doi:10.1017/S1462399405010082
French CR. Mechanistic Insights into Axenfeld–Rieger Syndrome from Zebrafish foxc1 and pitx2 Mutants. Int J Mol Sci. 2021;22(18):10001. doi:10.3390/ijms221810001
Williams AL, Bohnsack BL. The Ocular Neural Crest: Specification, Migration, and Then What? Front Cell Dev Biol. 2020;8. doi:10.3389/fcell.2020.595896
Stoller JZ, Epstein JA. Cardiac neural crest. Semin Cell Dev Biol. 2005;16(6):704-715. doi:10.1016/j.semcdb.2005.06.004
Chen L, Gage PJ. Heterozygous Pitx2 Null Mice Accurately Recapitulate the Ocular Features of Axenfeld-Rieger Syndrome and Congenital Glaucoma. Investigative Opthalmology & Visual Science. 2016;57(11):5023. doi:10.1167/iovs.16-19700
Holmberg J, Liu CY, Hjalt TA. PITX2 Gain-of-Function in Rieger Syndrome Eye Model. Am J Pathol. 2004;165(5):1633-1641. doi:10.1016/S0002-9440(10)63420-7
Berry FB, Lines MA, Oas JM, et al. Functional interactions between FOXC1 and PITX2 underlie the sensitivity to FOXC1 gene dose in Axenfeld–Rieger syndrome and anterior segment dysgenesis. Hum Mol Genet. 2006;15(6):905-919. doi:10.1093/hmg/ddl008
Dinalli Francisco A, Sande Miguel T, Luiza Mansur Souto A, Almeida da Costa D, Bastos Pereira M. Axenfeld-Rieger Syndrome: Case Report. Ophthalmology Research: An International Journal. Published online March 12, 2022:8-12. doi:10.9734/or/2022/v16i230229
Sim KT, Karri B, Kaye SB. Posterior embryotoxon may not be a forme fruste of Axenfeld-Rieger’s Syndrome. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2004;8(5):504-506. doi:10.1016/j.jaapos.2004.06.012
Khandwala NS, Ramappa M, Edward DP, Mocan MC. Axenfeld–Rieger syndrome in the pediatric population: A review. Taiwan J Ophthalmol. Published online November 24, 2023. doi:10.4103/tjo.TJO-D-23-00089
Zepeda EM, Branham K, Moroi SE, Bohnsack BL. Surgical outcomes of Glaucoma associated with Axenfeld-Rieger syndrome. BMC Ophthalmol. 2020;20(1):172. doi:10.1186/s12886-020-01417-w
Idrees F, Vaideanu D, Fraser SG, Sowden JC, Khaw PT. A Review of Anterior Segment Dysgeneses. Surv Ophthalmol. 2006;51(3):213-231. doi:10.1016/j.survophthal.2006.02.006
Gołaszewska K, Dub N, Saeed E, Mariak Z, Konopińska J. Axenfeld‐Rieger syndrome combined with a foveal anomaly in a three‐generation family: a case report. BMC Ophthalmol. 2021;21(1):154. doi:10.1186/s12886-021-01899-2
Ramesh P V, Devadas AK, Varsha V, et al. A rare case of unilateral Axenfeld–Rieger anomaly associated with optic disc coloboma: A multimodal imaging canvas. Indian J Ophthalmol. 2022;70(7):2645-2647. doi:10.4103/ijo.IJO_2950_21
Park SW, Kim HG, Heo H, Park YG. Anomalous Scleral Insertion of Superior Oblique in Axenfeld-Rieger Syndrome. Korean Journal of Ophthalmology. 2009;23(1):62. doi:10.3341/kjo.2009.23.1.62
Badnaware S, Srivastava VK, Chandel M, Gupta P, Fulzele P. Dental and Craniofacial Manifestation of Axenfeld-Rieger Syndrome: A Case Report. Cureus. Published online June 29, 2022. doi:10.7759/cureus.26442
Mammi I, Giorgio P De, Clementi M, Tenconi R. Cardiovascular anomaly in Rieger Syndrome, Heterogeneity or contiguity? Acta Ophthalmol Scand. 1998;76(4):509-512. doi:10.1034/j.1600-0420.1998.760424.x
Valikodath N, Johns JA, Godown J. Cardiac anomalies in Axenfeld–Rieger syndrome. Cardiol Young. 2023;33(7):1229-1231. doi:10.1017/S1047951122003857
Ali Z, Charan P, Said JM, Stark Z. Axenfeld–Rieger syndrome as rare cause of umbilical abnormality. Ultrasound in Obstetrics & Gynecology. 2019;54(2):276-277. doi:10.1002/uog.20129
Dunbar AC, McIntyre GT, Laverick S, Stevenson B. Axenfeld–Rieger syndrome: a case report. J Orthod. 2015;42(4):324-330. doi:10.1179/1465313315Y.0000000017
Kannu P, Oei P, Slater HR, Khammy O, Aftimos S. Epiphyseal dysplasia and other skeletal anomalies in a patient with the 6p25 microdeletion syndrome. Am J Med Genet A. 2006;140A(18):1955-1959. doi:10.1002/ajmg.a.31411
Grosso S, Farnetani MA, Berardi R, et al. Familial Axenfeld‐Rieger anomaly, cardiac malformations, and sensorineural hearing loss: A provisionally unique genetic syndrome? Am J Med Genet. 2002;111(2):182-186. doi:10.1002/ajmg.10493
Yamazaki H, Nakamura T, Hosono K, et al. Sensorineural hearing loss and hypoplastic cochlea in Axenfeld-Rieger syndrome with FOXC1 mutation. Auris Nasus Larynx. 2021;48(6):1204-1208. doi:10.1016/j.anl.2020.07.006
Saffari A, Ziegler A, Merkenschlager A, et al. Axenfeld-Rieger Anomaly and Neuropsychiatric Problems—More than Meets the Eye. Neuropediatrics. 2020;51(03):192-197. doi:10.1055/s-0039-3402037
Reis LM, Maheshwari M, Capasso J, et al. Axenfeld-Rieger syndrome: more than meets the eye. J Med Genet. 2023;60(4):368-379. doi:10.1136/jmg-2022-108646
Zamora EA, Tripathy K, Salini B. Axenfeld-Rieger Syndrome.; 2024.
Cazzolla AP, Testa NF, Spirito F, et al. Axenfeld–Rieger syndrome: orthopedic and orthodontic management in a pediatric patient: a case report. Head Face Med. 2022;18(1):25. doi:10.1186/s13005-022-00329-y
Valikodath N, Johns JA, Godown J. Cardiac anomalies in Axenfeld–Rieger syndrome. Cardiol Young. 2023;33(7):1229-1231. doi:10.1017/S1047951122003857
Aantaa R, Jalonen J. Perioperative use of α2-adrenoceptor agonists and the cardiac patient. Eur J Anaesthesiol. 2006;23(5):361-372. doi:10.1017/S0265021506000378
DeBry PW. Incidence of Late-Onset Bleb-Related Complications Following Trabeculectomy With Mitomycin. Archives of Ophthalmology. 2002;120(3):297. doi:10.1001/archopht.120.3.297
Meyer JJ, Lawrence SD. What’s new in laser treatment for glaucoma? Curr Opin Ophthalmol. 2012;23(2):111-117. doi:10.1097/ICU.0b013e32834f1887
Views:
29
Downloads:
22
Copyright (c) 2025 Matylda Czerwonka, Katarzyna Kurza, Julianna Podolec, Silvia Ciraolo, Agnieszka Kulczycka-Rowicka, Joanna Wojda, Katarzyna Lesiczka-Fedoryj, Anna Walczak, Zuzanna Kościuszko, Adam Sobiński

This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.

