INTRODUCTION: congenital central hypoventilation syndrome (cchs) is characterized by alveolar hypoventilation, autonomic nervous system (aNs) dysregulation (aNsD), and mutations in the paired-like homeobox 2B (PHOX2B) gene. aNsD in cchs affects multiple systems and includes ophthalmologic abnormalities. We hypothesized that quantitative pupil measures, obtained using pupillometry, would vary between cases with cchs and controls and within those with cchs by PHOX2B genotype. RESULTS: Measures known to be illustrative of sympathetic and parasympathetic response (prestimulus, maximum pupil diameter, percentage of pupil constriction after light stimulus, and average constriction and dilation velocities) were significantly reduced in those with cchs as compared with controls (all P < 0.05). DISCUSSION: These reductions are indicative of both sympathetic and parasympathetic deficits in cchs, which is in keeping with the role of PHOX2B in aNs development. an inverse linear relationship was apparent in pupil diameter and velocity measurements among the cases with cchs with the most common heterozygous PHOX2B polyalanine expansion repeat mutations, suggesting a graded phenotype/genotype dose response based on polyalanine repeat length. These results confirm our central hypotheses while offering the first objective measures of pupillary dysfunction and ophthalmologicspecific aNsD in cchs. METHODS: a total of 316 monocular measurements were taken under dark-adapted conditions with a fixed light stimulus from 22 PHOX2B mutation-confirmed cases with cchs and 68 healthy controls.
C ongenital central hypoventilation syndrome (CCHS) ischaracterized by central alveolar hypoventilation with autonomic nervous system dysregulation (ANSD) and is diagnosed in the absence of primary pulmonary, cardiac, or neuromuscular disease or a brainstem lesion that can account for the full phenotype (1). Discovery of the CCHS disease-defining gene, pairedlike homeobox 2B (PHOX2B) (2-4), and appreciation of its role in both embryologic development and regulatory function of the autonomic nervous system (ANS) (5-7), has broadened the understanding of the CCHS phenotype. The majority of individuals with CCHS are heterozygous for PHOX2B polyalanine repeat expansion mutations (PARMs), with a range of 24-33 alanine bases on the affected allele (20 repeats is normal; normal genotype is 20/20). Missense, nonsense, frameshift, and stop codon mutations in the PHOX2B gene, referred to as nonpolyalanine repeat expansion mutations (NPARMs), account for the remaining mutations in CCHS. Quantitative assessment of the respiratory control and ANSD features of CCHS by PHOX2B genotype has identified a graded genotype-phenotype relationship between mutation repeat length and ventilatory requirements (3,4), Hirschsprung disease (8,9), neural crest tumors (8,9), and cardiac sinus pauses (10).Detailed understanding of the ANSD features in CCHS requires targeted investigation with objective measures of all organ systems served by the ANS. Ophthalmologic abnormalities th...