Congenital Stromal Dystrophy of the Cornea Caused by
a Mutation in the Decorin Gene
Cecilie Bredrup,1,2 Per M. Knappskog,3,4 Jacek Majewski,5 Eyvind Rødahl,1,2 and
Helge Boman3,4
PURPOSE. To describe the clinical and pathologic characteristics
of a family with a congenital stromal dystrophy of the cornea
and to identify the genetic basis for this disorder.
METHODS. All family members in three generations underwent
ophthalmic examination. Stored corneal buttons were exam-
ined by transmission electron microscopy. Molecular genetic
studies, including a genome-wide scan with microsatellite
markers, linkage analysis, and DNA sequencing, were per-
formed.
RESULTS. The dystrophy was inherited in an autosomal domi-
nant pattern and was seen as clouded corneas shortly after
birth. No associated systemic abnormalities or congenital dis-
eases were present. After penetrating keratoplasty (PK), the
grafts remained completely clear in 56% of the eyes with a
mean (range) observation period of 19.5 years (3–36). Trans-
mission electron microscopy of corneal buttons revealed lamel-
lae with normal arrangement of collagen fibrils separated by
abnormal fibrillar layers. Genome-wide screening revealed link-
age to chromosome 12q22, with a maximum LOD score of
4.68 at D12S351. Subsequent sequencing of candidate genes
revealed a frameshift mutation in the DCN gene (c.967delT)
that encodes for decorin, predicting a C-terminal truncation of
the decorin protein (p.S323fsX5).
CONCLUSIONS. The authors hypothesize that truncated decorin
binds to collagen in a suboptimal way, disturbing the regularity
of corneal collagen fibril formation and thereby causing cor-
neal opacities. To the best of the authors’ knowledge, this is
the first description of a disorder associated with an inherited
alteration in the decorin gene in humans. (Invest Ophthalmol
Vis Sci. 2005;46:420 – 426) DOI:10.1167/iovs.04-0804
T he corneal dystrophies are inherited, bilateral, primary
alterations of the cornea that are not associated with prior
inflammation or secondary to systemic disease. Most show
autosomal dominant inheritance and appear in the first de-
cades of life. The corneal dystrophies that present at birth are
congenital hereditary endothelial dystrophy (CHED), posterior
From the Sections of 1Ophthalmology and 4Medical Genetics and
Molecular Medicine, Department of Clinical Medicine, University of
Bergen, Bergen, Norway; the 2Department of Ophthalmology and the
3
Center for Medical Genetics and Molecular Medicine, Haukeland Uni-
versity Hospital, Bergen, Norway; and the 5Laboratory of Statistical
Genetics, The Rockefeller University, New York, New York.
Supported in part by a grant from Kirsten Orning Olsen’s Foun-
dation (CB) and in part by Grant HG00008 from the National Human
Genome Research Institute (JM).
Submitted for publication July 9, 2004; revised September 13,
2004; accepted September 16, 2004.
Disclosure: C. Bredrup, None; P.M. Knappskog, None; J. Ma-
jewski, None; E. Rødahl, None; H. Boman, None
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked “advertise-
ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
Corresponding author: Eyvind Rødahl, Department of Ophthal-
mology, Haukeland University Hospital, 5021 Bergen, Norway;
eyvind.rodahl@helse-bergen.no.
420
polymorphous dystrophy, posterior amorphous corneal dystro-
phy, and congenital stromal dystrophy of the cornea. The first
three are associated with defects in endothelial functions. To
some extent, alterations in Descemet’s membrane and the
posterior stroma are also present, particularly in posterior
amorphous corneal dystrophy. The genetics of the corneal
dystrophies has recently been reviewed by Klintworth.1 CHED
type I and II have been localized to 20p11.2-q11.2 and 20p13,
respectively. Two variants of posterior polymorphous dystro-
phy are localized to 1p34.3-p32.3 and 20q11, respectively. The
genetic defect causing posterior amorphous corneal dystrophy
has not yet been found.1
Only a few reports of a true congenital hereditary stromal
corneal dystrophy have been published. Apart from the
present family, originally described by Odland,2 three pedi-
grees have been reported: a French family first described by
Turpin et al.,3 a branch of this family and an unrelated pedigree
reported by Witschel et al.,4 and a Belgian family consisting of
an affected mother and her son described by Van Ginder-
deuren et al.5 The clinical manifestations of the dystrophy
differ in some aspects between these families, and it is not
known whether they represent separate diseases or are differ-
ent clinical expressions of the same genetic defect (Table 1). A
molecular basis for the congenital stromal dystrophies has
hitherto not been found.
In the present work we re-examined the Norwegian family
reported by Odland,2 and we describe the results after pene-
trating keratoplasty (PK), the ultrastructure of the corneal
disease, and the mutation causing this congenital stromal dys-
trophy of the cornea.
MATERIALS AND METHODS
Subjects
The family pedigree is shown in Figure 1. All living members from the
third to the fifth generation were examined in this study. All the 11
affected family members participated, as well as 8 unaffected individ-
uals and 3 spouses. The affected members of the third and fourth
generation were also examined by Odland2 in 1968. The healthy
individuals III-2 and IV-3 who were spouses to affected family members
were not examined, but a blood sample was obtained from the latter
for genotyping. Individual III-6 was married to a healthy second cousin;
otherwise, no consanguinity was known.
Clinical Examination
The adult family members were invited to participate in the study, and
informed consent was obtained in accordance with the provisions of
the Declaration of Helsinki. Lifelong medical records of all affected
family members were available. A medical history was obtained, and
after the identification of a candidate gene, the affected family mem-
bers were also questioned in detail with regard to such symptoms as
scarring, fractures, and dental or joint problems. In addition, bone
mass measurements were performed on one affected man and his
unaffected brother. The family members underwent a thorough clini-
cal ophthalmic examination, including testing of visual acuity (Snellen
chart), measurement of intraocular pressure (Goldmann tonometry),
Investigative Ophthalmology & Visual Science, February 2005, Vol. 46, No. 2
Copyright © Association for Research in Vision and Ophthalmology
 IOVS, February 2005, Vol. 46, No. 2 Decorin Mutation in Congenital Stromal Dystrophy 421

pachymetry (Pachymeter Echograph; Quantel Medical, Clermont-Fer-

Slightly irregular posteriorly

rand, France) and keratometry (Auto Keratometer KM-500; Nidek,

6 of 18 minimal; 2 of 18
Gamagori, Japan). Two eyes that had not been subjected to kerato-

moderate to severe
Strabismus (4 of 11)
This Study

plasty and four eyes in three patients showing corneal opacities in the
corneal graft were examined by confocal microscopy (ConfoScan 3;

Irregular surface
Abnormal fibrils
Nidek). Slit lamp photographs were taken of all eyes.

Increased
Cf–0.63

Normal

Normal
Transmission Electron Microscopy

Cf–1.0
None

None

6–44
3–36
Yes
11

18
Corneal buttons obtained from affected individuals after corneal trans-
plantation had been fixed and stored in 2% glutaraldehyde in 0.2 M
cacodylate buffer. For this study, they were osmicated and embedded
in epoxy resin. Ultrathin sections were stained with 2% uranyl acetate
Van Ginderdeuren

and Reynold’s lead citrate and examined by transmission electron

Abnormal fibrils
et al.5 (2002)

microscopy (TEM) (JEM 1230; JEOL, Tokyo, Japan).

Photophobia

Genotyping
Normal

Normal
Normal

Normal
Normal
0.1–0.4

0.6–0.8
20–30
None
None

1–10
Yes

Genomic DNA was isolated from whole blood using a nucleic acid
2

extractor (model 341; Applied Biosystems, Foster City, CA). Five loci
(CHST6, KRT3, KRT12, TGFBI, and COL8A2), in which mutations have
been reported in patients with corneal dystrophy, were excluded as
candidates in preliminary studies by marker analysis (results not
Pouliquen et al.10* (1979)

Slightly irregular posteriorly

shown). The candidate regions CDPD1 and CHED1 on chromosome 20

Lacunes of abnormal fibrils

(loci not known) were also excluded by marker analysis.

A genome-wide scan was performed using a set of 400 microsatel-
lite markers with an average spacing of 10 cM (PRISM Linkage Mapping
Set MD, Ver. 2; ABI). PCR and pipetting were then performed (Catalyst
Abnormal fibrils

800 Turbo Laboratory workstation; ABI). The PCR products were

analyzed with a genetic analyzer (model 3100; and the GeneScan
Normal

Normal

Normal

Analysis software; ABI). High-density mapping was performed with

None

6–61

markers identified in the National Center for Biotechnology Informa-

ND

ND

ND
0.1
No

tion (NCBI) database (available at http://www.ncbi.nih.gov. Their

3

genomic sequences, and all markers used, are found in a single mega-
contig [accession number NT_019546]).
1 of 7 (diagnosed as edema)

Linkage Analysis
Family 2 (1978)
Witschel et al.4*

Genotyping data were screened for errors using the PedCheck pro-
gram.6 Markers exhibiting Mendelian inconsistencies were assigned an
Abnormal fibrils

“unknown” genotype. Two point and multipoint linkage analyses,

* Different branches of the family first described by Turpin et al. in 1939.3

along with determination of the most likely haplotypes, were per-

No banding

formed using the Allegro program.7 The analysis was performed under
Esotropia

0.04–0.1
Normal

Normal
Normal

Normal
0.1–0.2

the assumption of a dominant mode of inheritance with 99% pen-

3 of 4

5–14
6–22

etrance, 1% phenocopy rate, and 0.001 frequency of the disease allele.

TABLE 1. Families with Congenital Stromal Dystrophy of the Cornea

ND
No
4

Marker allele frequencies were estimated from the family used in this
study using the program PedManager (Mapmaker/PedManager).8

DNA Sequencing and Mutation Detection

Family 1 (1978)
Witschel et al.4

Esotropia

PCR primers for amplification of exons and flanking intron sequences

Normal

in the lumican, keratocan, and decorin genes were designed on com-

Yes
ND

ND

ND

ND
ND
ND
ND
ND

puter (Oligo 6.3 software; National Bioscience, Plymouth, MN) and

No
1

2
4
4
0

sequence information are available on request. PCR amplification was

performed at standard procedures using DNA polymerase (AmpliTaq
Cf, counting fingers; ND, no data.

Gold; ABI, or Taq; Qiagen, Hilden, Germany). After amplification, the

PCR products were treated with SAP/exonuclease I (Amersham Bio-
science, Uppsala, Sweden) and sequenced using a dye termination
Number of transplanted eyes

chemistry sequencing kit (Prism BigDye terminator, ver. 1.1; ABI), and
Other ocular abnormalities

Opacities in the graft (n)

analyzed on the genetic analyzer (model 3100; ABI). DNA sequences

Descemet’s membrane
Bowman’s membrane
Progression of opacities

Observation period (y)

were analyzed on computer (Staden software).9

Patients examined (n)

A simple test for the decorin c.967delT mutation was designed. The
Author

Corneal thickness

pertinent sequence was PCR amplified using the forward (5⬘-TTC TAT
Endothelium
Eye symptoms

Age at PK (y)

CGT TTC ATG TTG TAG G-3⬘) FAM-labeled and reverse (5⬘-GGG CTT
Epithelium
VA post-PK
Nystagmus

TCT TGA GAA TTA CTT AT-3⬘) primers, followed by size determina-
VA pre-PK

Stroma

tion of the fluorescence-labeled PCR product on a genetic analyzer

(model 310; ABI). DNA samples from 200 healthy local blood donors
TEM

were used as control samples.

422 Bredrup et al.
RESULTS
Medical History
The family members reported that corneal changes could be
observed in affected individuals during the first months after
birth. The patients described progressive deterioration of vi-
sual function over time. The patients did not have any other
symptoms from the eyes, especially no symptoms of corneal
erosions or photophobia. No other systemic abnormalities or
malformations were recorded. Specifically, there were no rec-
ognized problems related to skin, teeth, joints, or bones. Bone
density measurements were within normal range (data not
shown).
The two affected women in generation II died of breast
cancer at the age of 46 years and a brain tumor at the age of 58
years. One affected member in the third generation was 70
years old when he died of lymphoma/leukemia. Another indi-
vidual with the corneal disease had breast cancer when she
was 43 years old and colon cancer at the age of 70 years. The
unaffected II-3 died young in an accident. None of the unaf-
fected family members in the pedigree have had malignant
disease. One affected member of the family have had compli-
cated juvenile diabetes mellitus from the age of 12 years, but
this did not seem to have any influence on her corneal disease.
Her unaffected sister also has complicated juvenile diabetes
mellitus.
IOVS, February 2005, Vol. 46, No. 2
FIGURE 1. Pedigree of the family
with congenital stromal dystrophy.
(■, F) Affected persons.
Clinical Examination
Only four eyes had not been subjected to PK. Slit lamp exam-
ination of these eyes showed a slightly irregular surface.
Throughout the stroma a large number of small opacities were
seen (Fig. 2a). This was equally pronounced in all areas of the
cornea. The endothelium could not be studied in detail due to
these opacities. There was no sign of vascularization or staining
with fluorescein. The corneal sensitivity was normal or slightly
reduced.
Individual III-6 (age 73) had additional band-shaped kera-
topathy and III-1 (age 79) had arcus senilis in both eyes. Three
eyes had primary open-angle glaucoma (III-6 and both eyes of
IV-9), two of these eyes had not been subjected to keratoplasty.
An iris cyst has been observed unchanged for many years in
IV-2. Due to the opacities, gonioscopy was not possible. Bilat-
eral senile cataract was observed in the older women (III-1 and
III-6) as well as in IV-4 who also had diabetic retinopathy.
Examination of the fundus after corneal transplantation did not
reveal any abnormalities.
Among the 11 affected family members 4 individuals had
manifest strabismus; three had esotropia and one exotropia
(III-1, III-6, V-1, and V-8). No strabismus was observed in the
eight unaffected family members. There were no other motility
problems and no persons with nystagmus. The unaffected
individual IV-5 had diabetic retinopathy and cataract. No other
abnormalities were found in the eyes of the unaffected family
members.
FIGURE 2. Slit lamp photography. In
the arcuate beam from the slit lamp
the slightly irregular surface of the
cornea is seen. The corneal opacities,
more clearly seen in the anterior
stroma to the left of the image, are
identifiable as small flakes and spots
and were present throughout the en-
tire stromal thickness. With retroillu-
mination, the endothelium could not
be discerned, but the clouding of the
cornea is seen to the right of the
image (a). The graft of the right eye
of patient IV-7 remained clear (b) but
in the left eye, corneal clouding was
first seen after 15 months. The opac-
ities then developed rapidly, and af-
ter 3 years the graft was described to
have similar changes as the remain-
ing host cornea (c).
IOVS, February 2005, Vol. 46, No. 2 Decorin Mutation in Congenital Stromal Dystrophy 423

TABLE 2. Results after Penetrating Keratoplasty

Subjective Corneal
Age at Follow-up Refraction Opacities Thickness
Eye PK (y) VA Pre-PK Pre-PK Complications in Graft (␮m) VA Post-PK

III-1 (r) Cf No benefit 704

III-1 (l) 42 36 0.3 ⫺3.5, sphere None ⫹ 647 0.32
III-6 (r) 44 29 0.25 ⫺7, ⫺1.5 ⫻ 170 None 0 522 0.2
III-6 (l) Cf No benefit 665
IV-2 (r) 19 31 0.3 ⫺1, ⫺1 ⫻ 20 None ⫹ 581 0.25
IV-2 (l) 26 24 0.3 ⫺1 ⫻ 10 Iris prolapse, postoperative 0 566 0.5
IV-4 (r) 21 28 0.3 ⫺7, ⫺4 ⫻ 0 Iridocyclitis 0 600 0.1
IV-4 (l) 17 32 0.3 ⫺7, ⫺4 ⫻ 0 Corneal opacities (not a 0 623 0.16
recurrence); retransplant
IV-7 (r) 16 30 0.3 ⫹1, ⫺1 ⫻ 180 None 0 506 0.4
IV-7 (l) 14 32 Cf 0 None ⫹⫹⫹ 692 Cf
IV-9 (r) 0.63 ⫹3, ⫺3 ⫻ 0 658
IV-9 (l) 29 8 0.63 ⫹2.5, ⫺2.5 ⫻ 10 None 0 507 0.63
IV-10 (r) 17 27 0.63 ⫹1.5, ⫺2 ⫻ 10 Irrev. mydriasis, ⫹⫹ 662 0.5
iridocyclitis, secondary
glaucoma
IV-10 (l) 21 23 0.63 ⫹1.5, ⫺2 ⫻ 10 None ⫹ 595 0.63
V-1 (r) 16 9 0,1 No benefit Iris prolapse, traumatic ⫹ 549 0.16
V-1 (l) 20 5 0.3 No benefit None ⫹ 530 0.5
V-4 (r) 16 7 0.12 ⫹1, sphere None 0 532 0.5
V-4 (l) 6 17 0.16 ⫺3, sphere Keratitis, perforation; ⫹ 487 0.16
retransplant
V-6 (r) 14 3 0.3 0 None 0 545 1.0
V-6 (l) 0.63 ⫹1, ⫺0.75 ⫻ 25 664
V-8 (r) 10 7 Cf ⫺4.5 ⫻ 175 None 0 519 0.32
V-8 (l) 13 4 0.25 ⫹5, ⫺4.5 ⫻ 5 Macular edema 0 513 0.32

Eyes III-1 (r), III-6 (l), IV-9 (r), V-6 (l) had not been subjected to surgery but are included for completeness. (r), right eye; (l), left eye; Cf,
counting fingers; Irrev, irreversible; 0, no opacites; ⫹, minimal opacities; ⫹⫹, moderate opacities; ⫹⫹⫹, severe opacities.

The refractive errors in the affected family members are
shown in Table 2. The corrected visual acuity (VA) in unoper-
ated eyes varied from counting fingers in individuals III-1 and
III-6 to 0.63 in IV-9 and V-6. The VA of the eyes before corneal
transplantation was obtained from medical records. Best cor-
rected VA varied from counting fingers to 0.63, with a mean of
0.25. One eye was amblyopic in IV-7, V-1, and V-8. Six eyes
were myopic, eight emmetropic (or no benefit from corrective
glasses) and eight hypermetropic as shown in Table 2.
The mean (range) corneal diameter in affected eyes was
12.2 mm (11.5–12.5) which was similar to the diameter of 12.3
mm (12–13) in the eyes of the unaffected family members.
Pachymetry showed a mean corneal thickness in affected eyes
of 673 ␮m (658 –704) as opposed to the unaffected eyes,
which had a mean corneal thickness of 544 ␮m (511– 620).
The mean thickness of eyes with no postoperative opacities
was 543 ␮m (506 – 623) and in those with minimal clouding,
565 ␮m (487– 647). The eye with a corneal thickness of 487
␮m showed thinning of the corneal graft due to keratoconus.
The two eyes with moderate or severe opacities had a corneal
thickness of 662 and 692 ␮m, respectively (Table 2).
Penetrating Keratoplasty
Four individuals (III-1, III-6, IV-9, and V-6) had been treated
with PK in only one eye. The remaining seven affected indi-
viduals had undergone bilateral surgery. Thus, a total of 18 eyes
had undergone PK. The mean (range) age at surgery was 20
years (6 – 44). The mean follow-up time for these eyes was 19.5
years (3–36). Ten transplanted corneas (56%) were without
any sign of opacities, whereas six (33%) showed minimal
changes. In two (11%) individuals (IV-10 and IV-7) one eye had
moderate or severe opacities (Table 2, Fig. 2c). In patient IV-7
corneal clouding was first seen in the left eye 15 months after
transplantation. The opacities then developed rapidly and, af-
ter 3 years, the graft was described to have similar changes as
the remaining host cornea. The graft in his right eye has
remained clear for 30 years after surgery (Fig 2b). The right eye
of patient IV-10 had chronic iridocyclitis, secondary glaucoma
and persistent mydriasis after keratoplasty. The graft was de-
scribed as almost clear 21 years after the operation with VA
1.0. Now, 27 years after the keratoplasty, moderate clouding
was observed with a VA of 0.5. Only minimal opacities were
seen in the graft of his left eye with an observation period of 23
years.
The best corrected visual acuity after PK varied from count-
ing fingers to 1.0, with a mean value of 0.35 (Table 2). The eye
with the worst visual acuity was the eye with the most exten-
sive opacities. Three patients required retransplantation, one
(V-4) because of keratitis and perforation 7 months after sur-
gery, another (IV-4) because of superficial corneal opacities
that were not related to the stromal dystrophy (Table 2) and
patient IV-7, because of corneal clouding (data not shown).
Confocal Microscopy
When examined with confocal microscopy in vivo the super-
ficial epithelial cells of affected corneas appeared normal. From
the anterior stroma, there was an increased reflectivity caused
by the stromal opacities. The opacities prevented detailed
studies of the individual keratocytes and the endothelium.
When eyes with minimal clouding after keratoplasty were
studied, endothelial changes were found with low cell counts
(⬍700 cells/mm2), a high degree of polymegathism and pleo-
morphism. In one (V-4) of the four eyes studied, reflectivity
from the stroma prevented detailed examination of the endo-
thelium. In three eyes (IV-2 and both eyes of V-1) there were
changes in the stroma compatible with corneal edema (data
not shown).
424 Bredrup et al. IOVS, February 2005, Vol. 46, No. 2

FIGURE 3. In TEM micrographs, the dystrophic stroma is seen with lamellae of normal collagen fibrils (C)
separated by layers of abnormal collagen filaments (F) that were randomly arranged and loosely embedded
in an electron-lucent ground substance (I). The layers of abnormal filaments were present at all levels of
the corneal stroma. The loose layers were broader in the posterior than in the anterior stroma and seemed
to be closely related to keratocytes (K). The keratocytes had a normal appearance, without inclusions.
Descemet’s membrane (D) was of normal thickness, with a normal banding of the anterior portion. There
were no vacuoles or lacunas in Descemet’s membrane, but both the anterior and posterior borders were
slightly irregular. The corneal endothelium (E) was of normal thickness and appearance, with interdigi-
tating cell membranes. Original magnification (a) ⫻8000; (b) ⫻6000, (c) ⫻2600.

Transmission Electron Microscopy Linkage Analysis

When the corneal buttons were examined by TEM (Fig. 3a–c)
the corneal epithelium and its thin basement membrane were
found to be normal. The posterior part of Bowman’s layer was
slightly irregular. In the stroma lamellae of seemingly normal
collagen fibrils were separated by abnormal layers that con-
sisted of thin filaments. These filaments were randomly ar-
ranged and embedded in an electron-lucent ground substance.
The abnormal layers were broader in the posterior than in the
anterior stroma. The keratocytes had a normal appearance
without inclusions, but were observed more frequently in the
vicinity of the abnormal layers. Descemet’s membrane was of
normal thickness with a normal banding of the anterior por-
tion. Both the anterior and posterior border of Descemet’s
membrane were found to be irregular, and no vacuoles or
lacunas were seen. The corneal endothelium was of normal
thickness and appearance with interdigitating cell membranes.
A few endothelial cells appeared swollen and disrupted but
were in proper contact with neighboring cells. No infiltrating
cells were present in the cornea and no vessels were found.
The corneal button obtained after retransplantation of IV-7
showed an atrophic endothelium. The stroma was highly dis-
organized with widely spaced fibrils compatible with edema.
Occasional infiltrating cells were found. In addition, areas with
disorganized filaments were seen (data not shown).
Genome-wide screening was performed and revealed linkage
to chromosome 12q22 with a maximum LOD score of 4.68 at
the marker D12S351. No other candidate regions with LOD
scores ⬎1.5 were detected. High-resolution mapping was sub-
sequently used to narrow down the candidate region to an
8.4-Mb region between the markers D12S1719 and D12S101
(Fig. 4). Within this interval, haplotype analysis indicated that
all the affected family members shared a single ancestral hap-
lotype, whereas this haplotype was not present in any of the
unaffected individuals.
In our candidate region, we identified three genes known to
be relevant for the eye. Lumican, keratocan, and decorin are all
expressed in the human cornea. The coding sequences and
flanking introns of these genes were sequenced. No sequence
variants were detected in the lumican or the keratocan gene. In
the decorin gene, DNA sequencing identified a deletion of 1 bp
in exon 10 (c.967delT; Fig. 5). PCR amplification followed by
capillary electrophoresis verified a 1-bp deletion in all affected
family members. The deletion was observed neither in any
healthy members of the family nor in 200 control samples. The
c.967delT mutation leads to a frame shift and predicts the
expression of a truncated decorin protein lacking the 33 C-
terminal amino acids (p.S323fsX5).

Mode of Inheritance DISCUSSION

The dystrophy was present in both males and in females in
approximately equal proportions. Each generation had affected
individuals, and the disease was not transmitted through unaf-
fected persons. There were examples of male-to-male transmis-
sion (Fig. 1). Thus, the observed pattern was compatible with
autosomal dominant inheritance with complete penetrance.
The clinical and pathologic characteristics of a family with an
autosomal dominant congenital stromal dystrophy of the cor-
nea are described. Genetic analysis showed that the disorder is
cosegregating with a mutation in the decorin gene.
Support for the congenital nature of the disease is provided
by the parents of affected individuals who have observed the
IOVS, February 2005, Vol. 46, No. 2
FIGURE 4. Part of pedigree: the chromosome 12 haplotype in affected
family members is shown in the boxed branch of the family (left). The
family branch on the right exhibits the critical crossovers limiting the
candidate region to the 8430-kb interval between D12S1719 and
D12S101 (bold).
corneal changes shortly after birth. Odland,2 reported the
changes in one individual at the age of 1 year. He also noted
that the opacities increased with age indicating a progressive
nature of the disease.
As is common with diseases with congenital corneal opac-
ities refractive errors, amblyopia, and strabismus were ob-
served in the affected individuals. The manifestation of the
dystrophy in the present family differs in some aspects from
that reported in the other known families with congenital
stromal dystrophy of the cornea. The two affected patients in
the family reported by Van Ginderdeuren et al.,5 had severe
photophobia, and four of five patients described by Witschel et
al.,4 had a searching nystagmus and all presented with an
alternating esotropia. Nystagmus and photophobia were not
seen in any of the affected individuals in our study. However,
visual acuity was better in our patients than in those described
by Witschel et al., which could be relevant for the develop-
Decorin Mutation in Congenital Stromal Dystrophy 425
ment of nystagmus. Furthermore, the corneas in the other
pedigrees are described to be of normal thickness and were
measured to be so by Pouliquen et al.,10 whereas we observed
an increased corneal thickness. The different reports describe
similar morphologic changes in the stroma, but the status of
Descemet’s membrane varied significantly between studies
(Table 1). It is not uncommon that the clinical presentation of
corneal dystrophies varies from one individual to another, as
well as within a family that shares the same genetic defect.
DNA analysis would clarify whether the reported families with
congenital stromal dystrophy of the cornea represent different
clinical manifestations of the same genetic defect or separate
diseases.
In patients with corneal grafts, the thickness of the graft
was related to the degree of corneal clouding. When corneas
with opacities after grafting were examined by confocal mi-
croscopy and TEM, endothelial changes and corneal edema
was seen. In addition, when examined by TEM, there were
areas with collagen filaments different from the microfibrils
typical of the dystrophy itself. Although these changes most
likely represent corneal decompensation, a recurrence of the
dystrophy in the graft cannot be excluded.
Decorin, a dermatan sulfate proteoglycan, is known to be
involved in several important biological processes recently
reviewed by Goldoni et al.11 Among these are the ability to
modulate growth factor activity, tyrosine kinase receptor ac-
tivity, cancer growth, angiogenesis, tissue remodeling, bacte-
rial infection, and cardiovascular and periodontal disease.11
Decorin is important in collagen fibrillogenesis and binds to
multiple collagen types, including types I,12 II,13 III,14 and VI.15
Homozygous decorin knockout mice do not show any gross
anatomic abnormalities. Radiographic studies have not re-
vealed any alterations in bone mass. However, they have fragile
skin with dermal thinning and markedly reduced tensile
strength. Ultrastructural analyses have revealed abnormal col-
lagen morphology in skin and tendons, with coarser and irreg-
ular fiber outlines. The packing of the fibrils was shown to be
loose and irregular. No reference was made to any corneal
problems. Mice heterozygous for the knockout mutation are
normal.16
Decorin is known to modulate cancer growth.16 Although
homozygous decorin-knockout mice do not show increased
spontaneous tumorigenesis, Iozzo et al.17 reported that double-
knockout mice deficient in both decorin and p53 show a faster
rate of lymphoma development than deficiency of p53 alone.
There were several cases of malignant disorders among the
affected family members. However, due to the limited number
FIGURE 5. Mutation analysis of the decorin gene. Partial sequence
chromatograms displaying the wild-type (Wt) DNA sequence of a
normal person and the DNA sequence of a patient heterozygous for the
decorin c.967delT mutation.
426 Bredrup et al.
of cases, it is difficult to ascertain whether this occurs by
chance or is related to the mutation in the decorin gene.
In bone, decorin together with biglycan plays an important
role in the development of the initial osteoid matrix and also
during bone mineralization.18 The presence of biglycan can
compensate for a decorin deficiency,19 and evidence suggests
that these proteins act synergistic during bone formation.20
Bone-density measurements were normal in the two family
members we tested, and there were no indications of concur-
rent abnormalities or problems related to skin, bone, teeth, or
joints in this family. It has not been determined whether this is
because the disturbance of collagen structure caused by the
mutation we have detected is insignificant in these tissues, or
if the mutated decorin acts differently in the cornea than in
other connective tissues.
Corneal transparency requires the regular spacing of colla-
gen fibrils with uniform diameter and a regular interfibrillar
space. Experimental evidence suggests that the dermatan sul-
fate proteoglycans participate both in the lamellar adhesion
properties of collagen and in the control of the regular fibril–
fibril spacing found in the cornea.21 Decorin knockout mice
have clear corneas, indicating that decorin is not essential for
the regular collagen pattern needed for corneal transparency.
It is likely that other proteoglycans can compensate for the
absence of decorin in the cornea. We have found a frame shift
mutation that theoretically leads to alteration of four amino
acids and loss of the 33 C-terminal of the 359 decorin amino
acids. The decorin protein is composed of a central region of
leucine-rich repeats, which is flanked at either side by a cys-
teine-rich region. It is thought that the leucine-rich core has a
horseshoe shape and is the prime site of interaction with other
proteins.22 The side chains are important for maintaining in-
terfibrillar spacing of collagen.23 Modeling of human decorin
based on the porcine RNase inhibitor structure showed that a
single collagen triple helix could conceivably fit within the
area formed by the arch shape of decorin and thus coat the
collagen fibrils.24 We postulate that the mutant decorin inter-
act with collagen in a suboptimal way thereby disturbing the
regularity of corneal collagen and causing corneal opacities.
Thus, a cornea with homozygous decorin deficiency may be
clear, whereas a heterozygote with both a normal and a trun-
cated decorin product may have corneal clouding. Possibly,
corneal fibrilogenesis after birth explains the tendency for the
opacities to increase with age.
Acknowledgments
The authors thank genetic technologists Jorunn Skeie Bringsli and
Irene Britt Tjelflaat (Section of Medical Genetics and Molecular Medi-
cine, University of Bergen) for expert technical assistance; Professor
Gunnar Høvding (Department of Ophthalmology, Haukeland Univer-
sity Hospital) for providing the corneal buttons; Clara Beate Gjesdal
(Department of Reumatology, Haukeland University Hospital) for bone
density measurements; Senior Engineer Trygve Knag (Divison for Anat-
omy and Cell Biology, University of Bergen), for assistance in electron
microscopy; and Bård Kjersem and Unni Larsen (Department of Oph-
thalmology, Haukeland University Hospital) for technical assistance.
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