American Journal of M e d i c a l G e n e t i c s 45183-186 (1993)
Natural History of Blue Sclerae
in Osteogenesis Irnperfecta
D.Sillence, B. Butler, M. Latham, and K.Barlow
Medical Genetics and Dysmorphology Unit, Children’s Hospital, Camperdown, New South Wales, Australia
Scleral hue is an important sign which distin-
guishes 2 broad groupings of patients, those
with and those without blue sclerae with non-
lethal osteogenesis imperfecta (01).Individ-
uals with 01type I have distinctly blue sclerae
which remain intensely blue throughout life.
I n 01 type I11 and 01 type IV the sclerae may
also be blue at birth and during infancy, but
the intensity fades with time such that these
individuals have sclerae of normal hue by ad-
olescence and adult life. o 1993 Wiley-Liss, Inc.
KEY WORDS sclerae, blue, collagen linkage,
genetic heterogeneity, osteo-
genesis imperfecta
INTRODUCTION
Early in our first study of osteogenesis imperfecta (01)
(1975-19771, a most striking observation was made [Sil-
lence et al., 19791. The most severely deformed patients
had sclerae of normal color. This was surprising, because
if it was accepted that scleral blueness resulted from a
generalized defect in connective tissue, common to all
patients with 01,then one would have expected that the
most severely deformed patients, with presumably the
most extensive defect in connective tissue, would have
had the bluest sclerae. A decade later it is clear that the
explanation for this observation is that 01 is a genet-
ically heterogeneous group of disorders [Sillence, 19881.
Blue sclerae is a manifestation of some types of 01 but
not others. 01 type I represents a group of disorders
characterized by osteopenia leading to fractures and
distinctly blue sclerae [Sillence, 19811. Some affected
have normal teeth (Group A), while others have den-
tinogenesis imperfecta (DI) in addition to skeletal osteo-
penia [Paterson et al., 1983al. 01 type I1 is a group of
disorders characterized by perinatal death although
some affected particularly in a milder sub-group, sur-
Received for publication November 13, 1991; revision received
July 21, 1992.
Address reprint requests to Professor D. Sillence, Medical Ge- Package for the Social Sciences (SPSS),for scleral inten-
netics and Dysmorphology Unit, Children’s Hospital, Camper- sity by age, sex, deformity, age of onset of fractures, and
down, New South Wales 2050.
0 1993 Wiley-Liss, Inc.
vive for months to years. 01type 111encompasses a rare
syndrome with autosomal recessive inheritance of usu-
ally severe 01with progressive skeletal deformity. Indi-
viduals with 01 type IV have osteopenia but with nor-
mal sclerae in adult life [Paterson et al., 1983bl. Again
some families appeared to have DI in addition to skeletal
osteopenia, while others did not [Sillence, 19881. In spo-
radic instances of patients with normal sclerae and pro-
gressively deforming phenotype, it is not always possi-
ble to distinguish 01 type 111 from 01 type IV. These
patients are thus grouped as 01type III/IV although the
majority have heterozygous molecular defects and thus
represent fresh dominant mutations. The purpose of this
present study is to examine the variability and natural
history of blue sclerae in the 2 dominantly inherited
forms of osteogenesis imperfecta, 01 type I and 01type
IV.
METHOD
Individuals with (01)were ascertained through ge-
netics clinics, orthopaedists and parenupatient support
organizations in Australia and North America. A total
of 110 patients were included in this study. A detailed
data collection protocol was completed on each patient
including information on age, sex, family history, age of
onset of fractures, deformity, and scleral findings. Scle-
ral hue was estimated by comparison with a chart of 8
consecutive 50% dilutions of the basic hue which was
made by an ink manufacturer to match the hue of the
sclerae of a 4-year-old proposita, L.M., with 01 type I.
This patient had no skeletal deformity, height at the
third percentile, and normal teeth.
Scleral hue was graded from 1(almost white) through
to 8 (a 50% dilution of the basic hue). The intensity was
graded where possible in natural light through a win-
dow or outside light but not in direct sunlight or artifi-
cial light. The reading was taken in the lateral mid-
sclerae, usually of the left eye between the paler epicor-
neal area and the scleral reflection. The average inten-
sity was taken as the reading where there appeared to
be local areas of more intense blueness possibly due to
scleral thinning. The data was analyzed with Statistical
hearing impairment.
184 Sillence et al.

RESULTS However, there was correlation between 01 type and

With all 110 patients combined there was a wide scat-
ter of scleral intensity. However, when the group of fa-
milial cases of 01 with distinctly blue sclerae was an-
alyzed separately, it was apparent that in the majority
of cases (Fig. 1) the scleral intensity fell between grades
3 and 6 at birth. Scleral hue remained distinctly blue
throughout life. In 5 patients there was overlap in scle-
ral intensity (grade 2) with subjects who fall into the
group with normal sclerae. Three of these were from one
family, a mother and 2 children whose maternal grand-
mother had distinctly blue sclerae. The children were
felt to have 01 on the basis of unexplained joint hyper-
mobility and one had had a fracture. Their mother had
no other features of 01.
The remaining group of 27 patients had sclerae which
were bluish but in whom the intensity appeared t o fall
with increasing age (Fig. 2). Grade 1 and 2 is a grade of
blueness which could be encountered in normal persons
particularly normal children and women. This group of
27 patients included one proband with presumed re-
cessively inherited 01 type 111 [Fig. 3A in Sillence,
19811. Her scleral hue was 2 at age 6 years. It also
includes 22 families, a total of 26 individuals with 0 1
type IV.
Within the group with distinctly blue sclerae (01type
I) there is no correlation with age of onset of hearing loss.
hearing impairment over age 14 years (01 type I, 55%;
01 type III/IV, 29%).Similarly there was no correlation
between scleral hue and presencelabsence of deformity
although the degree of deformity (e.g., limb bowing,
scoliosis) was not coded particularly as the natural his-
tory of deformity in 01has been considerably altered by
current management (e.g., improved orthopaedic care,
intramedullary rodding).
DISCUSSION
Axmann [1831] was probably the first to draw atten-
tion to the non-skeletal features of 01 such as blue scle-
rae. Important reports and studies included those of Bell
[1928]. It is therefore important to note that no mention
is made of this most obvious of signs in the thesis by
Ekmann [19491.Indeed subsequent authors [Sillence et
al., 1979; Patterson et al., 1983a,bl have confirmed the
observation made by Smars [19611 and Bauze et al.
[19751 that the natural history of 01 was different de-
pending on the presence or absence of blue sclerae and
can be best accounted for by genetic heterogeneity. On
the basis of scleral hue families can be subdivided into
0 1 type I with distinctly blue sclerae and 01type IV with
bluish sclerae at birth but normal sclerae in adult life.
Individuals without a family history can be subdivided
into 01 type I and 01 type III/IV.

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AGE IN YEARS

Fig. 1. Graph of scleral hue versus age in 0 1 type I (number of subjects = 83).
 Sclerae in Osteogenesis Imperfecta 185

AGE IN YEARS

Fig. 2. Graph of scleral hue versus age in 01type IIYIV (numberof subjects = 27). One subject aged 6
years has a presumptivediagnosis of 01type III. All others are familial or sporadic instances of 01type IV.

The present study used a standardization of intensity
which is perhaps more accurate than that of other au-
thors who have come to similar conclusions [Bauzeet al.,
19751. The hue was not sky blue and did not correspond
exactly to any blue we could find on a commercial paint
chart. Accordingly the hue was mixed by a printer's ink
manufacturer to correspond with that seen in the eyes of
a 4-year-old child with distinctly blue sclerae. The hue is
produced by a mixture of blue, red, and black basic
tones. Dilutions were made with white pigment.
Blue sclerotics must be among the most unusual of
biological phenomena. The biophysical mechanism be-
hind the color is best explained and confirmed by Lant-
ing and colleagues 119851, who used a fiber optic light
scattering monitor to evaluate the sclerae in 2 patients
with 0 1 type I, one with 0 1 type III/IV, and 8 normal
control subjects. The blueness is due to differential path
scattering of light of different wavelengths by the mo-
lecular grating of the sclerae such that the short wave-
lengths (red, orange, yellow) are more effectively back-
scattered than the longer wavelengths (blue, indigo).
Thus the layer will look blue. The decreased back-scat-
tering could be due to decreased overall thickness or
decreased scattering coefficient that reflects decreased
thickness of collagen fibrils, decreased packing of col-
lagen fibrils, andlor increased amount of water between
collagen fibrils.
Eichholtz and Muller 119721found that in 2 cases of 0 1
type I the overall thickness of the sclerae was not re-
duced but that there was increased electron dense gran-
ular material (presumably proteoglycans) between scle-
ral collagen fibrils. On the other hand in 0 1 type I1 there
is evidence of decreased scleral thickness [Chan et al.,
19821 and decreased collagen microfibril diameters
[Bluemckeet al., 19721.Similar findings are observed in
skin collagen fibrils [Sillence and Rimoin, 19821. Sim-
ilarly in 0 1 type III/IV dying at birth there is evidence
for decreased scleral thickness [see Sillence and Rimoin,
1982, for review].
The clinical distinction between 0 1 type I and 01 type
IV is to some extent confirmed in a study of 38 families of
0 1 from 6 countries with dominantly inherited 01, em-
ploying polymorphic collagen RFLPs a t the COLlAl
and COLlA2 loci. Eight pedigrees with 0 1 type IV
showed consistent linkage with COLlA2 markers. In
the remaining 30 pedigrees a concordant locus was es-
tablished for 24 families with 17 linked to COLlAl and
7 to COLlA2 markers [Sykes et al., 19901.
The elucidation of the molecular pathogenetic mecha-
nism leading to blue sclerae is not unimportant as the
186 Sillence et al.
sclerae are a potential window on the mechanisms of
tissue disorder in other less accessibletissues, e.g., bone,
where the molecular organization of non-collagenous
proteins is obscured by bone mineral crystallites. Con-
firmation of the findings of Eichholtz and Mueller [19721
would potentially explain the reported short-term fluc-
tuation in scleral intensity in patients with 01type I and
01 type IV. It is conceivable that an increased inter-
fibrillar non-collagenous protein could vary in hydra-
tion state depending on short-term hormonal alter-
ations. These in turn could be reflected in alterations in
muscle tone which might increase liability to fractures.
Research into scleral biology and tissue biochemistry
in normal and 01 subjects would be advanced by care-
fully designed ultrastructural studies correlated with
biochemical analysis of tissue as well as collagens syn-
thesized by cultured skin fibroblasts in vitro. In the case
of natural or accidental death of 01subjects, permission
could be sought for eye donation for study at a few cen-
tres specializing in these studies. The benefits are likely
to be considerable. Morphologicaland biochemical study
of the sclerae in the Mov-13 mouse, a proposed mouse
model for dominantly inherited 01type I [Bonadio et al.,
19901and of the sclerae in the fro/fro mouse [Sillence et
al., 19931,a proposed mouse model for recessively inher-
ited 01type 111,may resolve some of the questions about
scleral pathology in 01.
ACKNOWLEDGMENTS
The authors are indebted to geneticists and ortho-
paedists and other colleagues in Australia and North
America who referred patients for study. This study was
supported in part by grants from the 01 Society of
N.S.W. (Australia) and the 01Foundation ( U S A . ) .Col-
lie and Son, North Melbourne, ink manufacturers, gen-
erously gave of their time to mix an ink which matched
the scleral hue in 01. The authors are particularly in-
debted to Kate Morley who has been responsible for the
01 Register at the Children’s Hospital, Camperdown.
The blue scale has been reproduced in Sillence and
Barlow [1992] through the generosity of IMS Publish-
ing, Crows Nest, N.S.W., and is available from the
author.
REFERENCES
Axmann E (1831):Merkwurdige Fragilitat der Knochen ohne dyskra-
sische Ursache alskrankhafte Eigenthumlickkeit dreur Geschwis-
ter. Ann Ges Heil (Karslruhe) 458.
Bauze FLJK, Smith R, Rancis MJO (1975):A new look at osteogenesis
irnperfecta. A clinical, radiological and biochemical study of forty-
two patients. J Bone Joint Surg 57B:2-12.
Bell J (1928):Blue Sclerotics and Fragility of Bone. In K. Pearson (ed)
“Treasury of Human Inheritance, Vol 11, Part 111.”Cambridge and
London: Cambridge University Press.
Bonadio J, Saunders TL, Tsai E, Goldstein SA, Morris-Wiman J,
Brinkley L, Dolan DF, Altschuler RA, Hawkins JE, Jr., Bateman
JF, Mascara T, Jaeriisch R (1990):Transgenic mouse model of the
mild dominant form of osteogenesis imperfecta. R o c Natl Acad Sci
USA 87:7145-7149.
Bluemcke S, NiedorfHR, Thiel H J and Langness U (1972):Histochemi-
cal and fine structural studies on the cornea in osteogenesis imper-
fecta. Virchows Arch (Zellpathologie) 11:124-32.
Chan CC, Green WR,De la Cruz ZC, Hillis A (1982): Ocular findings in
Osteogenesis Imperfecta Congenita. Arch Ophthal100:1459-1463.
Eichholtz W, Mueller I) (1972): Electron microscopy findings on the
cornea and sclera in osteogenesis imperfecta. Klin Monatsbl Au-
genheilkd 161:646-53.
Ekmann OJ (1949): Descriptionem et casus aliquot osteomalacia sis-
tens. Dissertatio Modica, Upsala, Sweden.
Lanting P, Borsboom P, Te Meerman G, Ten Kate L (1985): Decreased
scattering coefficient of blue sclerae. Clin Genet 27:187-190.
Paterson CR, McAllion S, Miller R (1983a): Heterogeneity of osteo-
genesis imperfecta type I. J Med Genet 20203-205.
Paterson CR, McAllion S, Miller R (1983b): Osteogenesis imperfecta
with dominant inheritance and normal sclerae. J Bone Joint Surg
65B335-39.
Sillence DO (1981): Osteogenesis imperfecta. An expanding panorama
of variants. Clin Orthop 159:ll-25.
Sillence DO (1988): Osteogenesis imperfecta. Nosology and genetics.
Ann NY Acad Sci 543:l-15.
Sillence DO, Senn A, Danks DM (1979): Genetic heterogeneity in
osteogenesis imperfecta. J Med Genet 16:lOl-116.
Sillence DO, Rimoin DL (1982): Morphological studies in osteogenesis
irnperfecta. In Akeson W, Bornstein P, Glimcher M (eds): “Heritable
Disorders of Connective Tissue.” St Louis: CV Mosby Co.
Sillence DO, Ritchie HE, Dibbayawan T, Eteson D, Brown K (1993):
Ragilitas ossium (fro/fro) in the mouse. A model for a recessively
inherited type of osteogenesis irnperfecta. Amer J Med Genet
45:(this issue).
Sillence DO, Barlow K (1992): “Osteogenesis Imperfecta. A Handbook
for Medical Practitioners and Health Care Professionals.” Sydney:
IMS Publishing, pp 1-29.
Smars, G (1961): “Osteogenesis irnperfecta in Sweden.” Stockholm:
Scandinavian University Books, pp 1-240.
Sykes B, Ogilvie D, Wordsworth P, Wallis G, Matthew C, Beighton P,
Nicholls A, Pope FM, Thompson E, Tsipouras P, Schwartz R,
Jensson 0,Arnason A, Borresou AL, Heiberg A, Frey D, Steinmann
B (1990): Consistent, linkage of dominantly inherited osteogenesis
imperfecta to the type I collagen loci: COLlAl and COLlA2. Am J
Hum Genet 46:293--307.