TCF4 trinucleotide repeat expansion in Swedish cases with Fuchs' endothelial corneal dystrophy

Acta Ophthalmol. 2022 Aug;100(5):541-548. doi: 10.1111/aos.15032. Epub 2021 Oct 13.


Purpose: Fuchs' endothelial corneal dystrophy (FECD) has been considered a genetically heterogeneous disease but is increasingly associated with the transcription factor 4 (TCF4) gene. This study investigates the prevalence of the cytosine-thymine-guanine (CTG)n repeat expansion in TCF4 among FECD patients in northern Sweden coupled to the phenotype.

Methods: Blood samples were collected from 85 FECD cases at different stages. Short tandem repeat PCR and triplet repeat-primed PCR were applied in order to determine TCF4 (CTG)n genotype.

Results: A (CTG)n repeat expansion (n > 50) in TCF4 was identified in 76 of 85 FECD cases (89.4%) and in four of 102 controls (3.9%). The median (CTG)n repeat length was 81 (IQR 39.3) in mild FECD and 87 (IQR 13.0) in severe FECD (p = 0.01). A higher number of (CTG)n repeats in an expanded TCF4 allele increased the probability of severe FECD. Other ocular surgery was overrepresented in FECD cases without a (CTG)n repeat expansion (44.4%, n = 4) compared with 3.9% (n = 3) in FECD cases with an (CTG)n repeat expansion (p < 0.001).

Conclusion: In northern Sweden, the FECD phenotype is associated with (CTG)n expansion in the TCF4 gene, with nearly 90% of patients being hetero- or homozygous for (CTG)n expansion over 50 repeats. Furthermore, the severity of FECD was associated with the repeat length in the TCF4 gene. Ocular surgery might act as an environmental factor explaining the clinical disease in FECD without a repeat expansion in TCF4.

Keywords: TCF4; Fuchs' endothelial corneal dystrophy; cornea; genetic aetiology; trinucleotide repeat disorders.

MeSH terms

  • Fuchs' Endothelial Dystrophy* / epidemiology
  • Fuchs' Endothelial Dystrophy* / genetics
  • Genetic Predisposition to Disease
  • Humans
  • Sweden / epidemiology
  • Transcription Factor 4* / genetics
  • Trinucleotide Repeat Expansion*


  • TCF4 protein, human
  • Transcription Factor 4