ZC3H11A mutations cause high myopia by triggering PI3K-AKT and NF-κB mediated inflammatory reactions in humans and mice

Reviewer #1 (Public Review):

Chen and colleagues investigated ZC3H11A as a potential cause of high myopia (HM) in humans through the analysis of exome sequencing in 1,015 adolescents and experiments involving Zc3h11a knock-out mice. The authors showed four possibly pathogenic missense variants in four adolescents with HM. After that, the authors presented the phenotypic features of Zc3h11a knock-out mice, the result of RNA-sequencing, and a comparison of mRNA and protein levels of the functional candidates between wild-type and Zc3h11a knock-out mice. Based on their observations, the authors concluded that ZC3H11A protein contributes to the early onset of myopia.

The strengths of this manuscript include: (1) successful identification of characteristic ophthalmic phenotypes in Zc3h11a knock-out mice, (2) demonstration of biological features related to myopia, such as PI3K-AKT and NF-kB pathways, and (3) inclusion of supporting human genetic data in individuals with HM. On the other hand, the weaknesses of this paper appear to be: (1) the lack of robust evidence from their genomic analysis, and (2) insufficient evidence to support phenotypic similarity between humans with ZC3H11A mutations and Zc3h11a knock-out mice. Given that the biological mechanisms of high myopia are not fully understood, the identification of a novel gene is valuable. As described in the manuscript, it is worth noting that the previous study using myopic mouse model has implicated the role of ZC3H11A in the etiology of myopia (Fan et al. Plos Genet 2012).

Specific comments:
1. I am concerned about the certainty of similarity in phenotypes between individuals with ZC3H11A mutation and Zc3h11a knock-out mice. A crucial point would be that there are no statistical differences in axial lengths (ALs) between wild-type and Zc3h11a knock-out mice at 8W and 10W, even though ALs in the individuals with ZC3H11A mutation were long. I would also like to note that the phenotypic information of these individuals is not available in the manuscript, although the authors indicated the suppressed b-wave amplitude in Zc3h11a knock-out mice. Considering that the authors described that "Detailed ophthalmic examinations were performed (lines: 321-323)", the detailed clinical features of these individuals should be included in the manuscript.

2. The term "pathogenic variant" should be used cautiously. Please clarify the pathogenicity of the reported variants in accordance with the ACMG guideline.

3. The genetic analysis does not fully support the claim that ZC3H11A is causative for HM. While the authors showed the rare allele frequencies and high CADD scores (> 20) of the identified variants, these were insufficient to establish causality. A helpful way to assess the causality would be performing a segregation analysis. An alternative approach is to show significant association by performing a gene-level association test. Assessing the pathogenicity of the variants using various prediction software, such as SIFT, PolyPhen2, and REVEL may also provide additional supportive evidence.

4. As shown in Figure 2, significant differences in refraction were observed from 4 weeks to 10 weeks. Nevertheless, no differences were observed in AL, anterior/vitreous chamber depth, and lens depth. The author should experimentally clarify what factors contribute to the observed difference in refraction.

5. The gene names should be italicized throughout the manuscript.

6. Table 1: providing chromosomal positions and rs numbers (if available) would be helpful for readers.

7. Figure 5b, c, and d: the results of pathway analysis and GO enrichment analysis are difficult to interpret due to the small font size. It would be preferable to present these results in tables. Moreover, the authors should set a significant threshold in the enrichment analyses.

Reviewer #2 (Public Review):

Summary:
Chong Chen and colleagues reported that mutations were identified in the ZC3H11A gene in four adolescents from 1015 high myopia subjects in their myopia cohort. They further generated Zc3h11a knockout mice utilizing the CRISPR/Cas9 technology. They analyzed the heterozygotes knockout mice compared to control littermates and found refractive error changes, electrophysiological differences, and retinal inflammation-related gene expression differences. They concluded that ZC3H11A may play a role in the early onset of myopia by regulating inflammatory responses.

Strengths:
Data were shown from both clinical cohort and animal models.

Weaknesses:
Their findings are interesting and important, however; they need to resolve several points to make the current conclusion.

1. They described the ZC3H11A gene as a pathogenic variant for high myopia. It should be classified as pathogenic according to the guidelines of the American College of Medical Genetics and Genomics (Richards et al., Genet Med 17(5):405-24, 2015). The modes of inheritance for the families need to be shown. They also described identifying the gene as a "new" candidate. It should be checked in databases such as gnomAD and ClinVar, and any previous publications and be declared as a novel variant.

2. The phenotypes of the heterozygote mice are weak overall. The het mice showed mild to moderate myopic refractive shifts from 4 to 10 weeks of age. However, this cannot be explained by other ocular biometrics such as anterior chamber depth or lens thickness. Some differences are found between het and WT littermates in axial length and vitreous chamber depth but disappear after 8 weeks old. Furthermore, the early differences are not enough to explain the refractive error changes. They mentioned that they did not use homozygotes because of the embryonic lethality. I would strongly suggest employing conditional knockout systems to analyze homozygotes. This will also be able to identify the causative tissues/cells because they assume bipolar cells are functional. The cells in the retinal pigment epithelium and choroid are also important to contribute to myopia development.

3. Their hypothesis regarding inflammatory gene changes and myopic development is not logical. Are the inflammatory responses evoked from bipolar cells? Did the mice show an accumulation of inflammatory cells in the inner retina? Visible retinal inflammation is not generally seen in either early-onset or high-myopia human subjects. Can this be seen in the actual subjects in the cohort? To me, this is difficult to adapt the retina-to-sclera signaling they mentioned in the discussion so far. Egr-1 may be examined as described.

Reviewer #3 (Public Review):

Chen et al have identified a new candidate gene for high myopia, ZC3H11A, and using a knock-out mouse model, have attempted to validate it as a myopia gene and explain a potential mechanism. They identified 4 heterozygous missense variants in highly myopic teenagers. These variants are in conserved regions of the protein, but the authors provide no evidence that these specific variants affect protein function. They then created a knock-out mouse. Heterozygotes show myopia at all ages examined but increased axial length only at very early ages. Unfortunately, the authors do not address this point or examine corneal structure in these animals. They show that the mice have decreased B-wave amplitude on electroretinogram (a sign of retinal dysfunction associated with bipolar cells), and decreased expression of a bipolar cell marker, PKC. They do not address, however, whether there are fewer bipolar cells, or simply decreased expression of the marker protein. On electron microscopy, there are morphologic differences in the outer nuclear layer (where bipolar, amacrine, and horizontal cell bodies reside). Transcriptome analysis identified over 700 differentially expressed genes. The authors chose to focus on the PI3K-AKT and NF-B signaling pathways and show changes in the expression of genes and proteins in those pathways, including PI3K, AKT, IB, NF-B, TGF-1, MMP-2, and IL-6, although there is very high variability between animals. They propose that myopia may develop in these animals either as a result of visual abnormality (decreased bipolar cell function in the retina) or by alteration of NF-B signaling. These data provide an interesting new candidate variant for the development of high myopia, and provide additional data that MMP2 and IL6 have a role in myopia development, but do not support the claim of the title that myopia is caused by an inflammatory reaction.