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Original Investigation
June 27, 2019

Genetic Variants Associated With Corneal Biomechanical Properties and Potentially Conferring Susceptibility to Keratoconus in a Genome-Wide Association Study

Author Affiliations
  • 1Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
  • 2National Institute of Health Research Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and University College London, London, United Kingdom
  • 3UCL Institute of Ophthalmology, University College London, London, England
  • 4Department of Ophthalmology, King’s College London, St Thomas’ Hospital, London, United Kingdom
JAMA Ophthalmol. 2019;137(9):1005-1012. doi:10.1001/jamaophthalmol.2019.2058
Key Points

Question  What genetic variants are associated with corneal hysteresis and corneal resistance factor, and do these variants confer susceptibility to keratoconus?

Findings  This genome-wide association study of 9029 unique participants identified 9 loci associated with corneal hysteresis and corneal resistance factor in the European Prospective Investigation into Cancer and Nutrition–Norfolk and TwinsUK studies. Four loci have been previously reported as associated with corneal disease, and the other 5 showed a suggestive association with keratoconus in our study; some loci were not previously reported for central corneal thickness.

Meaning  The findings appear to support the role of corneal hysteresis and corneal resistance factor as corneal biomarkers that may provide complementary information to central corneal thickness about corneal properties.


Importance  Keratoconus is an important cause of visual loss in young adults, but little is known about its genetic causes. Understanding the genetic determinants of corneal biomechanical factors may in turn teach us about keratoconus etiology.

Objectives  To identify genetic associations with corneal biomechanical properties and to examine whether these genetic variants are associated with keratoconus.

Design, Setting, and Participants  A stage 1 discovery and replication genome-wide association study (GWAS) of corneal biomechanical properties was performed in 2 cross-sectional populations (6645 participants from the European Prospective Investigation into Cancer and Nutrition [EPIC]–Norfolk Eye Study and 2384 participants from the TwinsUK study). In stage 2, the association of genetic determinants identified in stage 1 with keratoconus was examined in a case-control study. A total of 752 patients with keratoconus were compared with 974 TwinsUK participants (undergoing direct sequencing) or 13 828 EPIC-Norfolk participants (undergoing genotyping and imputation) who were not part of the stage 1 analysis. Data were collected from March 1, 1993, through March 13, 2017, and analyzed from November 1, 2015, through February 1, 2018.

Exposures  In stage 1, allele dosage at genome-wide single-nucleotide polymorphisms (SNPs); in stage 2, allele dosage at SNPs with genome-wide significance (P < 5 × 10−8) in stage 1 and not previously reported as associated with corneal disease.

Main Outcomes and Measures  In stage 1, corneal hysteresis (CH) and corneal resistance factor (CRF), measured with the Ocular Response Analyzer (ORA); in stage 2, association with keratoconus compared with controls.

Results  Among 6645 participants in the discovery cohort (3635 women (54.7%); mean age, 69 years [range, 48-92 years]), 7 genome-wide significant loci associated with CH or CRF were identified that were independently replicated. Two further suggestive loci were identified after meta-analysis. To date, 5 of the identified loci, at ANAPC1, ADAMTS8, ADAMTS17, ABCA6, and COL6A1, have not previously been reported as associated with corneal disease. The ABCA6 locus (rs77542162) was associated with keratoconus using the TwinsUK (odds ratio [OR], 0.50; 95% CI, 0.27-0.92; P = .03) and EPIC-Norfolk controls (OR, 0.39; 95% CI, 0.22-0.70; P = .002). The other loci were associated with keratoconus using TwinsUK (OR per effect allele for ADAMTS8, 0.51 [95% CI, 0.37-0.71; P = 7.9 × 10−5]; for COL6A1, 1.65 [95% CI, 1.05-2.59; P = .03]) or EPIC-Norfolk (OR per effect allele for ANAPC1, 0.78 [95% CI, 0.68-0.89; P = 3.7 × 10−4]; for ADAMTS17, 0.82 [95% CI, 0.68-0.99; P = .04]) controls.

Conclusions and Relevance  Five loci that are associated with corneal biomechanical properties and that have suggestive associations with keratoconus were reported. These findings suggest the role of type VI collagen, extracellular matrix, and connective-tissue development for corneal biomechanics and keratoconus and the role of CH and CRF as biomarkers for keratoconus.