Fuchs endothelial corneal dystrophy (FECD) is a common disease for which corneal transplantation is the only treatment option in advanced stages, and alternative treatment strategies are urgently required. Expansion (≥50 copies) of a non-coding trinucleotide repeat in TCF4 confers >76-fold risk for FECD in our large cohort of affected individuals. An FECD subject-derived corneal endothelial cell (CEC) model was developed to probe disease mechanism and investigate therapeutic approaches. The CEC model demonstrated that the repeat expansion leads to nuclear RNA foci, with the sequestration of splicing factor proteins (MBNL1 and MBNL2) to the foci and altered mRNA processing. Antisense oligonucleotide (ASO) treatment led to a significant reduction in the incidence of nuclear foci, MBNL1 recruitment to the foci, and downstream aberrant splicing events, suggesting functional rescue. This proof-of-concept study highlights the potential of a targeted ASO therapy to treat the accessible and tractable corneal tissue affected by this repeat expansion-mediated disease.

Department of Ophthalmology and Twin Research King's College London London SE1 7EH UK

Institute of Aging and Chronic Disease University of Liverpool Liverpool L7 8TX UK

ProQR Therapeutics Zernikedreef 9 2333 CK Leiden the Netherlands

Research Unit for Rare Diseases Department of Paediatrics and Adolescent Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Ke Karlovu 2 Prague 128 08 Czech Republic

Research Unit for Rare Diseases Department of Paediatrics and Adolescent Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Ke Karlovu 2 Prague 128 08 Czech Republic; Department of Ophthalmology 1st Faculty of Medicine Charles University and General University Hospital Prague U nemocnice 2 Prague Czech Republic

UCL Institute of Ophthalmology London ECIV 9EL UK

UCL Institute of Ophthalmology London ECIV 9EL UK; Moorfields Eye Hospital London EC1V 2PD UK

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