NM_000329.3(RPE65):c.272G>A (p.Arg91Gln) is a missense variant that replaces arginine with glutamine at position 91 in RPE65. At least one proband harboring this variant has been genotyped by next-generation sequencing analysis of 586 candidate genes without an alternative explanation for visual impairment (2 pts), with phenotypes including congenital onset (1 pt), abnormal best corrected visual acuity test (1 pt), extinguished scotopic (0.5 pts) and photopic (1 pt) electroretinogram responses, bone spicule pigmentation (0.5 pts), white or yellow dots in the fundus (2 pts), and nystagmus (1 pt), which together are highly specific for RPE65-related recessive retinopathy (9 points, PP4_Moderate). This variant has also been reported in at least 2 probands with early-onset severe retinal dystrophy who were compound heterozygous with either the c.1022T>C (p.Leu341Ser) variant or the c.370C>T (p.Arg124Ter) variant suspected in trans (1 point, PMID: 32865313, PMID: 27102010), both of which were previously classified pathogenic by the ClinGen LCA / eoRD VCEP. This variant has also been reported in the homozygous state in at least 2 probands with early-onset severe retinal dystrophy (1 point, PMID: 32865313, PMID: 34492281; 2 total points, PM3_Strong). The variant has been reported to segregate with childhood-onset severe retinal dystrophy through a proband plus 1 similarly affected relative, both of whom harbor the variant present in the compound heterozygous state with the c.725+4A>G variant confirmed in trans (PP1; PMID: 11462243). This variant is present in gnomAD v.2.1.1 at a Grpmax allele frequency of 0.0001609, with 8 alleles / 24940 total alleles in the African / African-American population, which is lower than the ClinGen LCA / eoRD VCEP PM2_Supporting threshold of <0.0002 (PM2_Supporting). The computational predictor REVEL gives a score of 0.659, which is above the ClinGen LCA / eoRD VCEP threshold of ≥ 0.644 and predicts a damaging effect on RPE65 function (PP3). The variant also exhibited 1.33% enzymatic activity in a retinoid isomerase assay relative to the wild-type control, which is lower than the ClinGen LCA / eoRD PS3_Supporting threshold of <10% activity, indicating that it triggers a severe defect in protein function (PS3_Supporting, Table 2, PMID: 19431183). Two other missense variants encoding different amino acid substitutions at the same codon have been reported in association with RPE65-related recessive retinopathy (PMID: 17724218, PMID: 9501220). However, c.271C>T (p.Arg91Trp) and c.272G>C (p.Arg91Pro) have not yet been classified by the ClinGen LCA / eoRD VCEP, and PM5 was not considered to avoid circularity. In summary, this variant meets the criteria to be classified as pathogenic for RPE65-related recessive retinopathy based on the ACMG/AMP criteria applied, as specified by the ClinGen LCA/eoRD VCEP: PS3_Supporting, PM2_Supporting, PM3_Strong, PP1, PP3, PP4_Moderate (VCEP specifications version 1.0.0; date of approval 09/21/2023).