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Published in final edited form as: Nat Genet. 2016 February ; 48(2): 189–194. doi:10.1038/ng.3482.
Genome-wide association analysis identifies TXNRD2, ATXN2 and FOXC1 as susceptibility loci for primary open angle glaucoma
A full list of authors and affiliations appears at the end of the article.
Abstract
Primary open angle glaucoma (POAG) is a leading cause of blindness world-wide. To identify new susceptibility loci, we meta-analyzed GWAS results from 8 independent studies from the United States (3,853 cases and 33,480 controls) and investigated the most significant SNPs in two Australian studies (1,252 cases and 2,592 controls), 3 European studies (875 cases and 4,107 controls) and a Singaporean Chinese study (1,037 cases and 2,543 controls). A meta-analysis of top SNPs identified three novel loci: rs35934224[T] within TXNRD2 (odds ratio (OR) = 0.78, P = 4.05×10−11 encoding a mitochondrial protein required for redox homeostasis; rs7137828[T] within ATXN2 (OR = 1.17, P = 8.73×10−10), and rs2745572[A] upstream of FOXC1 (OR = 1.17, P = 1.76×10−10). Using RT-PCR and immunohistochemistry, we show TXNRD2 and ATXN2 expression in retinal ganglion cells and the optic nerve head. These results identify new pathways underlying POAG susceptibility and suggest novel targets for preventative therapies.
Glaucoma is a clinically and genetically complex disease that is the leading cause of irreversible blindness worldwide1,2. Primary open-angle glaucoma (POAG), the most common form of the disease in most populations3, is characterized by retinal ganglion cell apoptosis and progressive optic nerve damage4. While recent genome-wide association studies (GWAS) have identified interesting POAG risk loci5–9, these account for only a fraction of disease heritability. To identify new POAG loci, we have completed a metaanalysis of GWAS summary findings of individuals of European descent from the United States with replication in an Australian study (ANZRAG) and further evaluation in a second Australian study (BMES), 3 European studies and a Singaporean Chinese dataset.
Users may view, print, copy, and download text and data-mine the content in such documents, for the purposes of academic research, subject always to the full Conditions of use: http://www.nature.com/authors/editorial_policies/license.html#terms Correspondence: Janey L. Wiggs, ; Email: janey_wiggs@meei.harvard.edu 55A list of members and affiliations is provided in the Supplementary Note. *These authors contributed equally #These authors contributed equally. Author Contributions J.N.C.B., L.R.P., J.H.K., J.L.H, and J.L.W. were involved in designing the study. R.R.A., C.C.K., M.B., D.L.B., H.C., W.G.C., G.C., I.D.V., J.H.F., P.F., C.F., D.G., T.G., A.W.H., F.H., D.J.H., R.K.L., Z.L., P.R.L., D.A.M., P.M., P.M., S.E.M., S.A.P., Q.Q., T.R., J.E.R., P.M.R., E.R., R.R., J.S.S., W.K.S., K.S., A.J.S., R.M.T., F.T., A.C.V., D.V., G.W., T.Y.W., B.L.Y., D.J.Z., K.Z., N.W., B.W., R.N.W., M.A.P.-V., T.A., E.N.V., S.M., J.E.C., M.A.H., L.R.P., J.L.H., and J.L.W. were involved in participant recruitment, sample collection or genotyping. Analysis was performed by J.N.C.B., S.J.L., J.H.K., P.G., C.C.K., K.P.B., A.A.B., A.B., H.A., D.I.C., R.P.I., P.H., C.A.G., A.A-K., C.-Y.C., A.P.K., M.R., Y.E.S., S.S.V., J.J. W., K.S., C.J.H., P.K., L.R.P., S.M., J.L.H., and J.L.W. Designing and conducting the laboratory experiments were performed by K.W.P., Y.L., G.H., and J.L.W. Clinician assessments were performed by R.R.A., D.L.B., W.G.C., J.H.F., D.G., A.W.H., R.K.L., P.R.L., D.A.M., S.E.M., T.R., R.R., J.S.S., K.S., A.J.S., F.T., A.C.V., G.W., T.Y.W., D.J.Z., K.Z., J.E.C., L.R.P., and J.L.W. The initial draft was written by J.N.C.B., L.R.P. J.H.K., J.L.H. and J.L.W.

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For stage 1 (discovery) we meta-analyzed summary data from 8 independent datasets (3,853
cases and 33,480 controls; Supplementary Table 1) with European ancestry from the United
States collectively referred to as the National Eye Institute Glaucoma Human Genetics
Collaboration Heritable Overall Operational Database (NEIGHBORHOOD). For all 8
NEIGHBORHOOD studies cases were primarily defined as at least 1 reliable visual field
showing loss consistent with glaucoma, without a secondary cause, or CDR (cup-to-disc
ratio) ≥ 0.7 or CDR asymmetry ≥ 0.2 or documented progression of optic nerve degeneration (in the Ocular Hypertension Treatment Study [OHTS])10. Controls had CDR <0.7.
Additionally, for all datasets except OHTS, controls had intraocular pressure (IOP) of < 21
mmHg (Supplementary Table 2). For each dataset, site-specific quality control (sample and genotype call rates ≥ 95%), principal components analysis (EIGENSTRAT11), and imputation (IMPUTE212 or MACH13,14) were completed using the 1000 Genomes Project
reference panel (March 2012) (Supplementary Note, Supplementary Table 3). Imputed
variants with minor allele frequencies <5% or imputation quality scores (r2) <0.7 were
removed prior to analysis. Dosage data, in the form of estimated genotypic probabilities, were analyzed in ProbABEL15 for each dataset using logistic regression models, adjusting
for age, sex, any significant eigenvectors and study-specific covariates. Genomic inflation was less than 1.05 (λ-value) for each individual dataset (Supplementary Figure 1). Estimated genotypic probabilities for 6,425,680 variants were meta-analyzed in METAL16 using the
inverse variance weighted method. To confirm that the results were not skewed by a
particular dataset we completed a sensitivity analysis by selectively removing each dataset
and meta-analyzing the remaining 7. The ORs from each grouping of 7 datasets were highly
correlated with the results obtained from all 8 datasets (Supplementary Figure 2).

The stage 1 genome-wide association results are shown in Supplementary Figure 3, and the association results for all SNPs with P < 1×10−5 are shown in Supplementary Table 4. One SNP (rs2745572[A]) located in a novel region on 6p 50Kb 5′ of FOXC1 reached genomewide significance (OR = 1.25, P = 2.36×10−9) in stage 1 (Table 1). Additionally, 873 SNPs including SNPs located in regions not previously associated with POAG on 1p, 2p, 2q, 5p, 6p, 6q, 10q, 12q, 20p, and 22p had P< 1×10−5 (Supplementary Table 4).
Next we investigated the associations of the most significant stage 1 SNPs (P< 1×10−5) in a replication dataset of European Caucasians from Australia (ANZRAG, Australian and New Zealand Registry of Advanced Glaucoma; 1,155 cases and 1,992 controls) (Supplementary Note), and performed a meta-analysis of these SNPs in the NEIGHBORHOOD and ANZRAG datasets using the effect sizes and their standard errors (stage 2). In the metaanalysis, SNPs in novel regions 50kb 5′ of FOXC1 [top SNP rs2745572[[A], OR = 1.23, P = 6.5×10−11], within intron 14 of ATXN2 [top SNP rs7137828 [T], OR = 1.18, P = 9.2×10−9] and within intron 11 of TXNRD2 [top SNP rs35934224[T], OR = 0.77, P = 1.8×10−9] reached genome-wide significance (Table 1, Supplementary Table 5). The regional association results for these SNPs are shown in Figure 1.

For each of the 3 novel regions reaching genome-wide significance after stage 2, we further examined their association with POAG in: a second Australian dataset (BMES, Blue Mountains Eye Study) (107 cases and 600 controls); 3 European datasets (875 cases and 4,107 controls in total); and a study of Singaporean Chinese (1,037 cases and 2,543

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controls); (stage 3). Meta-analysis of all datasets exceeded genome-wide significance for all three top SNPs (Figure 2, Supplementary Figure 4): TXNRD2 rs35934224[T], combined P = 4.05×10−11, OR = 0.78; ATXN2 rs7137828[T], combined P = 4.40×10−10, OR = 1.17; and FOXC1 rs2745572[A], combined P = 1.76×10−10, OR = 1.17 (Supplementary Tables 6 and 7). The ATXN2 top SNP (rs7137828) is very rare in the Singaporean Chinese population
and thus could not be evaluated.

SNPs in the GAS7 region, previously associated with intraocular pressure (IOP), a quantitative trait that, when elevated, is a risk factor for glaucoma17–19, were significantly associated with POAG after stage 2 (top SNP rs9897123[T], OR = 0.83, P = 5.85×10−10) (Table 1). Other POAG loci identified in recent studies5–9 were also confirmed, including
TMCO1, CDKN2BAS, SIX6, ABCA1, and AFAP1 (Table 1, Supplementary Table 8). PMM2 SNPs recently identified in Chinese POAG9 were nominally associated with POAG
(top SNP rs12444233[T], OR = 1.13, P = 0.0016).
POAG, like many complex human diseases, displays clinical sub-phenotypes20,21. In
particular, optic nerve degeneration in POAG can occur without elevation of IOP, a clinical subtype defined as normal-tension glaucoma (NTG)22. The NEIGHBORHOOD POAG
dataset included 725 NTG cases (maximum IOP ≤ 21 mm Hg) and 1,868 high tension
glaucoma (HTG) (maximum IOP > 21 mm Hg) cases (pretreatment IOP was not available
for 1260 cases). The meta-analysis of NTG cases (using all the controls from the datasets
with NTG cases) revealed one novel locus on chromosome 12q (rs2041895 [C], OR= 1.48, P = 2.41×10−8) in stage 1 (Supplementary Figure 5, Supplementary Table 9). The direction of
effect was consistent (OR=1.15) in the ANZRAG NTG dataset, but did not reach
significance (P=0.11) and the combined association result (NEIGHBORHOOD + ANZRAG) fell just short of genome-wide significance (P= 8.01×10−8), possibly due to a
smaller number of NTG cases in the ANZRAG dataset (N=363). In the NEIGHBORHOOD discovery dataset we confirmed previous NTG associations on 9p7 (CDKN2BAS top SNP rs1333037[T], OR = 1.67, P=1.35×10−12) and 8q227 (top SNP, rs284491[T], OR = 0.66, P=2.30×10−8) and in the HTG subgroup, (1,868 cases) confirmed associations with TMCO16,17, and SIX67,23 (Supplementary Figure 6, Supplementary Table 10). The FOXC1
region SNPs associated with POAG overall were also significant in the NEIGHBORHOOD HTG subgroup (most significant SNP rs2317961, OR =0.76, P = 2.58×10−8).

To assess the possible functional effects of SNPs at the three newly identified POAG loci, we accessed and applied data from ENCODE24, SCAN (eQTL)25, GENEVAR (eQTL)26, GTEx (eQTL)27 and RegulomeDBv228,29. After stage 2, seven SNPs reached genome-wide
significance in the FOXC1 region (Supplementary Table 5) and all seven of these are located
50Kb 5′ to FOXC1 in a region annotated by ENCODE as regulatory (Supplementary Figure
7) and are associated with enhancers in several cell types (P=0.01, RegulomeDBv2). The
most significant SNP (rs2745572) is evolutionarily conserved (GERP = 1.8) and alters a
Barhl1 transcription factor binding site (RegulomeDBv2). In zebrafish Barhl1 is expressed in distinct retinal cell lineages and is differentially regulated by Atoh730, a retinal-specific transcription factor that has been previously associated with optic nerve area31 and glaucoma32. In the NEIGHBORHOOD meta-analysis we found nominal evidence for
association with ATOH7 and POAG (top SNP rs1867567[A] P = 0.042, OR, 1.07).

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Four SNPs in the ATXN2 region were significantly associated with POAG after stage 2
(Supplementary Table 5). These SNPs are located in genomic regions enriched for enhancers
(P = 0.01) in lymphoid cells (RegulomeDBv2). The most significant SNP (rs7137828) is
located in a SP1 transcription factor binding site, and another associated SNP, rs653178 which is in linkage disequilibrium with rs7137828 (R2>0.8, Caucasian European Ancestry)
is located in an Esr2 (Estrogen receptor 2) binding site. Both SP1 and Esr2 are expressed in retinal cells33, 34 and could influence expression of ATXN235.

The TXNRD2 region that includes 22 associated SNPs at the genome-wide level after stage 2 (Supplementary Table 5) is significantly enriched for enhancers (P=1×10−6, RegulomeDBv2) and DNaseI hypersensitivity sites (P = 4.3×10−5, RegulomeDBv2) in
multiple cell types. Additionally, 6 of the TXNRD2 SNPs are cis eQTLs significantly
affecting TXNRD2 transcript levels in MuTHer (Multiple Tissue Human Expression Resource) Twins36 in lymphoblasts and skin (P=1×10−8, GENEVAR; Supplementary Figure
8). The top SNP (rs35934224) is also an eQTL in skin using RNA seq and 1000 Genomes imputation (P=2.32×10−13)37. All 22 TXNRD2 SNPs are significant cis eQTLs (P<1×10−4) in the GTEx database27 in thyroid tissue and 19 are significant eQTLs in tibial nerve tissue
(Supplementary Figure 9). The most significant TXNRD2 SNP (rs35934224) is located in a
binding site for NRSF (neuron-restrictive silencer factor, also known as REST, (repressor
element 1-silencing transcription factor), a transcription factor that potently protects neurons from oxidative stress38.

FOXC1 is a member of the forkhead family of transcription factors and rare coding
sequence mutations (missense, nonsense, and CNVs) are known to cause anterior segment dysgenesis and early-onset glaucoma with dominant inheritance39,40. FOXC1 has not been
previously implicated in common adult-onset forms of glaucoma including POAG or HTG. Interestingly, association over GMDS, located 3′ to FOXC1, has been identified in a study using some of the same samples used here8. In our study we found genome-wide significant association adjacent to FOXC1 in the 5′ regulatory region and less significant association in GMDS (top SNP rs9378638, OR = 0.83, P = 7.50×10−6). The top SNPs in the two regions
are approximately 400kb apart and are not in linkage disequilibrium. Conditional analysis confirmed that the odds ratio and P-value for the significantly associated SNPs 5′ to FOXC1
are unchanged by conditioning on the GMDS peak SNP, suggesting that these are independent associations (Supplementary Figure 10). The 5′ regulatory SNPs associated
with POAG and HTG identified by this study could be involved in regulation of FOXC1
expression.

The ATXN2 and TXNRD2 genomic regions have not been previously associated with
POAG or with any glaucoma-related quantitative traits such as optic nerve parameters or
IOP. Expansions of an ATXN2 CAG repeat can cause spinocerebellar ataxia 2 with optic
atrophy and intermediate expansions can contribute to development of amyotrophic lateral sclerosis (ALS)41. Interestingly, very recently two other genes known to be responsible for
Mendelian forms of NTG have also been shown to contribute to ALS (amyotrophic lateral sclerosis)42,43. The ATXN2-SH3 region has been associated with retinal venular caliber in Caucasians with European ancestry44. We analyzed the expression of ATXN2 mRNA in
normal human ocular tissues by RT-PCR and found expression in the cornea, trabecular

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meshwork, ciliary body, retina and optic nerve (Supplementary Figure 11). Immuno-labeling of sections of a normal mouse eye showed evidence of Atxn2 in the retinal ganglion cells and optic nerve (Figure 3).

TXNRD2 codes for thioredoxin reductase 2, a mitochondrial protein necessary for reducing
damaging reactive oxygen species generated by oxidative phosphorylation and other mitochondrial functions45. Cellular oxidative stress has been hypothesized as a cause of retinal ganglion cell dysfunction in glaucoma46 and over-expression of thioredoxin 2, the
substrate of thioredoxin reductase 2 (encoded by TXNRD2), increased retinal ganglion cell survival in an experimental glaucoma model47. We confirmed by RT-PCR that TXNRD2 is
expressed in normal human ocular tissue (Supplementary Figure 11) including the retina and
optic nerve. Immuno-labeling in mice showed strong staining in retinal ganglion cells as
well as in the optic nerve (Figure 3). These data suggest that reduction of reactive oxygen
species by TXNRD2 could prevent mitochondrial dysfunction and retinal ganglion cell
apoptosis in glaucoma. TXNRD2 is the first mitochondrial protein associated with glaucoma
risk.

In this study, common variants near FOXC1, ATXN2 and TXNRD2 were identified as new risk loci for POAG. These genes suggest novel pathways that may contribute to glaucoma development including abnormal ocular development (FOXC1), neuro-degeneration (ATXN2) and mitochondrial dysfunction secondary to accumulating reactive oxygen species (TXNRD2). Targeting these pathways could lead to effective and potentially preventative glaucoma therapies.

URLS

ENCODE, http://www.genome.gov/encode/ and http://genome.ucsc.edu/ENCODE/ GENEVAR, http://www.sanger.ac.uk/resources/software/genevar/ GTEx, http://www.gtexportal.org/home/ IMPUTE, http://mathgen.stats.ox.ac.uk/impute/impute.html LocusZoom, (http://csg.sph.umich.edu/locuszoom/) MACH, http://csg.sph.umich.edu/abecasis/MACH/download/ METAL, http://csg.sph.umich.edu/abecasis/metal/index.html NEIGHBORHOOD, http://glaucomagenetics.org ProbABEL, http://www.genabel.org/ RegulomeDBv2, http://www.broadinstitute.org/mammals/haploreg/haploreg.php SCAN, http://www.scandb.org/ SHAPEIT, https://mathgen.stats.ox.ac.uk/genetics_software/shapeit/shapeit.html 1000 Genomes Project, http://www.1000genomes.org/

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Data access
Summary data for the NEIGHBORHOOD POAG meta-analysis is available on the NEIGHBORHOOD website (URL listed above, see ‘Publications’).

Online Methods
Study design
Imputed genotypes (1000 Genomes panel, March 2012) for 3,853 cases and 33,480 controls from 8 independent datasets were used as the discovery cohort for this genome-wide association study for Primary Open Angle Glaucoma (POAG) (stage 1). The association results for the top SNPs from the discovery cohort were replicated in 1,155 cases and 1,992 controls from an Australian POAG study of Caucasians of European ancestry (stage 2) followed by further replication (stage 3) in a second Australian study, BMES (Blue Mountains Eye Study) and 3 European studies (EPIC (European Prospective Investigation into Cancer-Norfolk Eye Study), GER (Germany), UK (United Kingdom); (982 cases and 4,707 controls total), and a Singaporean Chinese datasest of 1,037 cases and 2,543 controls. The details for all datasets including genotyping platforms, quality control, imputation methods and diagnostic criteria are listed in the Supplementary Notes.
Meta-analysis (Discovery, stage 1)
Quality-control was performed for each data set as described in the Supplementary Note. Overall sample and genotype call rates were ≥ 95% for each site. Samples with Log R ratio (LRR) and B allele frequency (BAF) values suggestive of copy number variants were removed prior to analysis. Principal components (eigenvectors) were computed for all participants using EIGENSTRAT11. For each dataset logistic regression was performed in ProbABEL15 for all analyses (POAG overall, HTG, NTG), controlling for age, sex, and study-specific covariates including study-specific eigenvectors. Each analysis was evaluated separately for overall genomic inflation (implementing the R package GenABEL) (λ-value ≤ 1.05 for each dataset) (Supplementary Figure 1). Results were meta-analyzed in METAL16 implementing the inverse variance weighted method and applying genomic control correction.
Replication (Stage 2 and 3) Loci of interest in the discovery cohort (NEIGHBORHOOD; P<1×10−5) were evaluated in the first replication cohort (ANZRAG) and meta-analyzed with the NEIGHBORHOOD results (stage 2). The top SNPs for the three novel regions were evaluated in 5 additional datasets, one Australian (BMES), 3 European (EPIC, GER, UK) and a Singaporean Chinese dataset.
Power calculations Power calculations were done as described48. For the stage 1 discovery analysis, power calculations using disease prevalence of 2%49 indicated that there was 96% power of detecting loci at P < 1.0 × 10−5 (the threshold for carrying over to stage 2) at minor allele frequencies as low as 30% with per-allele odds ratios of 1.17. The entire sample set (stages

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1, 2 and 3) had 99% power to detect loci at P < 5.0 × 10−8 at minor allele frequencies as low as 30% with per-allele odds ratios as low as 1.17.

Candidate genes and functional effects
Genes of interest in the associated region were identified using Ensembl50, UCSC genome Bioinformatics51, and Genecards52. To predict functional effects of the top POAG associated SNPs, we used the ENCODE project data24, HaploReg v228 and RegulomeDB29. We used SCAN25, Genevar26 and GTEx27 and a study of UK twins using RNA seq and 1000 genomes imputation37 to investigate expression quantitative trait loci within genomic
regions of interest.

Statistical analyses
Conditional analyses were done using the top SNPs in the FOXC1, ATXN2, and TXNRD2 regions as well as the top SNP in the previously reported GMDS region8 conditioning on the risk allele in the region of interest. Conditional analyses were performed using GCTA (Genome Complex Trait Analysis)53.
Forest plots to visualize the effect sizes of top SNPs in each region by dataset were created using the rmeta package in R. The odds ratios and 95% confidence intervals for each displayed SNP were plotted and the P-values listed for each analysis (Figure 2) and each NEIGHBORHOOD dataset (Supplementary Figure 4).
Sensitivity analysis using the leave-one-out method was done by excluding each NEIGHBORHOOD dataset from a meta-analysis of the other 7 datasets. We compared the odds ratios from these analyses by calculating the Pearson’s product-moment correlation coefficient between each leave-one-out analysis and the overall meta-analysis of eight NEIGHBORHOOD datasets (Stage 1), as shown in Supplementary Figure 2. Correlations were calculated in R using the corrplot package and ellipse option.

Expression analysis of genes at associated loci in ocular tissues
Total RNA was extracted from dissected tissues from normal human donor eyes as previously described54,55 using an RNA isolation kit from Life Technologies (Carlsbad, CA, USA). Reverse Transcriptional reactions were completed using SuperScript III reverse transcriptase from Life Technologies. Primer sequences were designed to specifically amplify TXNRD2 and ATXN2. PCR reactions were performed using the recommended conditions with Platinum Taq DNA polymerase (Life Technologies, Carlsbad, CA, USA) using a Touch Down program. Amplified PCR products were visualized by gel electrophoresis with 2% agarose gel.

Immunohistochemistry
C57BL/6J mice (males and females) were maintained on a 12/12 hours light/dark cycle. All experiments were approved by the Animal Care and Use Committee at The Jackson Laboratory. Eyes from 2–4 months old C57BL/6J mice were enucleated and fixed in 4% Paraformaldehyde for 2 hours, rinsed in 0.1M Phosphate buffer, immersed in 30% sucrose overnight and frozen in OCT. 15 mm sections were placed on Fisherbrand Superfrost Plus

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Slides and stored at −70°C until required. Sections were incubated overnight at 4°C in the following primary antibodies: rabbit anti TXNRD2 (1:50 Acris); rabbit anti-ATXN2 (1:50, Acris). All antibodies were diluted in PBT (1×PBS, 1% TritonX-100). Sections were blocked in 2.5% chicken serum (in PBT) for 1 hour, then incubated overnight at 4oC. After primary incubation, sections were washed 3 times in PBT and incubated with the secondary antibody (goat anti-rabbit IgG) for 4hrs at 4°C. All sections were then counterstained with DAPI and mounted with Aqua PolyMount. Images were collected on a Leica SP5 Confocal microscope. For each antibody, at least 3 sections from 6 eyes were assessed. Antibodies were obtained from Acris: Ataxin 2, Catalogue number: 21776-1 AP; Immunogen: Ag16470; Genebank ID (clone info): BC114546; Purification method: Antifen affinity purification; Txnrd2: Catalogue number: 16360-1-AP; Immunogen: Ag8367; Genebank ID (clone info): BC007489; Purification method: Antifen affinity purification.

All images in Figure 3 were taken on a Leica SP5 confocal microscope. Images in left and center panels were taken with a 20× glycerol objective, right panels were taken with a 63× glycerol objective. Excitation was performed using a 405 Diode laser (DAPI) and Argon laser (ATXN2 or TXNRD2). Collection was performed using sequential scanning: scan 1 = PMT 1 (gain 966) for DAPI, scan 2 = PMT 2 (gain 1013) for ATXN2 or TXNRD2.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Authors

Jessica N. Cooke Bailey1,*, Stephanie J. Loomis2,*, Jae H. Kang3, R. Rand Allingham4, Puya Gharahkhani5, Chiea Chuen Khor6,7, Kathryn P. Burdon8,9, Hugues Aschard10, Daniel I. Chasman11, Robert P. Igo Jr.1, Pirro G. Hysi12, Craig A. Glastonbury12, Allison Ashley-Koch13, Murray Brilliant14, Andrew A. Brown15, Donald L. Budenz16, Alfonso Buil15, Ching-Yu Cheng7,17,18, Hyon Choi19, William G. Christen11, Gary Curhan3,20, Immaculata De Vivo3, John H. Fingert21,22, Paul J. Foster23,24, Charles Fuchs3,25, Douglas Gaasterland26, Terry Gaasterland27, Alex W. Hewitt28,29, Frank Hu10,30, David J. Hunter10,31, Anthony P. Khawaja32, Richard K. Lee33, Zheng Li6, Paul R. Lichter34, David A. Mackey8,35, Peter McGuffin36, Paul Mitchell37, Sayoko E. Moroi34, Shamira A. Perera17,38, Keating W. Pepper39, Qibin Qi40, Tony Realini41, Julia E. Richards34,42, Paul M Ridker11, Eric Rimm3,10,30, Robert Ritch43, Marylyn Ritchie44, Joel S. Schuman45, William K. Scott46, Kuldev Singh47, Arthur J. Sit48, Yeunjoo E. Song1, Rulla M. Tamimi3, Fotis Topouzis49, Ananth C. Viswanathan23, Shefali Setia Verma44, Douglas Vollrath50, Jie Jin Wang37, Nicole Weisschuh51, Bernd Wissinger51, Gadi Wollstein45, Tien Y. Wong7,17, Brian L. Yaspan52, Donald J. Zack53, Kang Zhang54, EPIC-Norfolk Eye Study55, ANZRAG consortium55, Robert N. Weinreb54, Margaret A. PericakVance46, Kerrin Small12, Christopher J. Hammond12, Tin Aung17,18, Yutao Liu56,57, Eranga N. Vithana17,18, Stuart MacGregor5, Jamie E. Craig9, Peter Kraft10,31, Gareth Howell39, Michael A. Hauser4,13, Louis R. Pasquale2,3, Jonathan L. Haines1,#, and Janey L. Wiggs2,#

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Affiliations
1Department of Epidemiology and Biostatistics, Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, OH 2Department
of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA 3Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 4Department of Ophthalmology Duke University Medical Center, Durham, NC 5QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 6Division of Human Genetics, Genome Institute of Singapore 7Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore 8Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia 9Department of Ophthalmology, Flinders University, Adelaide, SA, Australia 10Department of Epidemiology, Harvard School of Public Health, Boston, MA 11Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 12Department of Twin
Research and Genetic Epidemiology, King’s College London, London, UK 13Department of Medicine, Duke University Medical Center, Durham, NC 14Center
for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, WI 15Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, Switzerland 16Department of Ophthalmology, University of North Carolina, Chapel Hill, NC 17Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 18Eye Academic Clinical Program, Duke-National University of Singapore Graduate Medical School, Singapore 19Section of Rheumatology and
Clinical Epidemiology Unit, Boston University School of Medicine, Boston, MA 20Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 21Department of Ophthalmology University of Iowa, College of Medicine, Iowa City, IO 22Department of Anatomy and Cell Biology, University of Iowa, College of Medicine, Iowa City, IO 23National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital 24Department of Ophthalmology, University of Cambridge, London 25Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 26Eye Doctors of Washington, Chevy Chase, MD 27Scripps Genome Center, University of California at San Diego, San Diego, CA 28Centre for Eye Research Australia, University of Melbourne, Australia 29Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia 30Department of Nutrition, Harvard School of Public Health, Boston, MA 31Program in Genetic Epidemiology and Statistical Genetics, Harvard School of Public Health, Boston, MA 32Department of Public Health and Primary Care,
Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK 33Bascom Palmer Eye Institute University of Miami Miller School of Medicine, Miami, FL 34Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 35Centre for Ophthalmology and Visual
Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia 36Medical Research Council Social Genetic and Developmental
Psychiatry Research Centre, Institute of Psychiatry, King’s College, London, UK 37Centre for Vision Research, Westmead Millennium Institute, University of Sydney,

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Westmead, New South Wales, Australia 38Duke-National University of Singapore Graduate Medical School, Singapore 39The Jackson Laboratory, Bar Harbor, ME 40Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 41Department of Ophthalmology, West Virginia University Eye Institute, Morgantown, WV 42Department of Epidemiology, University of Michigan, Ann Arbor, MI 43Einhorn Clinical Research Center, Department of Ophthalmology, New York Eye and Ear Infirmary of Mt. Sinai, New York, NY 44The Center for Systems Genomics, The Pennsylvania State University, University Park, PA 45Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 46Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, FL 47Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA 48Department of Ophthalmology, Mayo Clinic, Rochester, MN 49Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece 50Department of Genetics, Stanford University School of Medicine, Palo Alto, CA 51Institute for Ophthalmic Research, Centre for Ophthalmology, University of Tübingen, Germany 52Genentech, San Francisco, CA 53Wilmer Eye Institute, Johns Hopkins University Hospital, Baltimore, MD 54Hamilton Glaucoma Center, Shiley Eye Institute, University of California, San Diego, CA 56Department of Cellular Biology and Anatomy, Georgia Regents University, Augusta, GA 57James & Jean Culver Vision Discovery Institute, Georgia Regents University, Augusta, GA
Acknowledgments
The NEIGHBORHOOD data collection and analysis is supported by NIH/NEI R01EY022305 (JL Wiggs). Support for recruitment of ANZRAG (Australian and New Zealand Registry of Advanced Glaucoma) was provided by the Royal Australian and New Zealand College of Ophthalmology (RANZCO) Eye Foundation and by the National Health and Medical Research Council (NHMRC) of Australia (#535074, #1031362 and #1023911, #1021105). EPIC-Norfolk infrastructure and core functions are supported by grants from the Medical Research Council (G1000143) and Cancer Research UK (C864/A14136). BMES (Blue Mountains Eye Study) was supported by the NHMRC, Canberra Australia, the Centre for Clinical Research Excellence in Translational Clinical Research in Eye Diseases, NHMRC Senior Research Fellowships and the Wellcome Trust, UK. The South London Case-Control cohort (UK) collection and genotyping was supported by a National Institute of Health Research (NIHR) Senior Research Fellowship (CJ Hammond), and analysis was supported by a Fight for Sight Early Career Investigator Award (PJ Hysi). The Singapore study of EN Vithana, T Aung, and CC KHor, was supported by a Biomedical Research Council (BMRC) grant in Singapore, Ref: BMRC 10/1/35/19/675. This research was also partly supported by a grant (NMRC/TCR/008-SERI/2013) from the Singapore National Research Foundation under its Translational and Clinical Research Flagship Programme and administered by the Singapore Ministry of Health’s National Medical Research Council. Additional acknowledgment and funding details are in the Supplementary Note.
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Figure 1. Association results for the regions reaching genome-wide significance after stage 2 These plots show the regional association and recombination rates for the top SNPs in the discovery cohort (NEIGHBORHOOD, 3,853 cases and 33,480 controls) after meta-analysis with data for these SNPs from ANZRAG (1,155 cases and 1,992 controls). In each plot, the solid diamond indicates the top-ranked SNP in the region based on two-sided P values. The colored box at the right or left corner of each plot indicates the pairwise correlation (r2) between the top SNP and the other SNPs in the region. The blue spikes show the estimated recombination rates. The box underneath each plot shows the gene annotations in the region.
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Each plot was created using LocusZoom for the top-ranked SNP in each region with a 400
kb region surrounding it. (a) The top SNP for this plot is rs2745572 on chromosome 6 upstream of FOXC1 with P = 6.50×10−11. (b) The top SNP for this plot is rs7137828 on chromosome 12 within ATXN2 with P = 9.20×10−9. (c) The top SNP for this plot is rs35934224 on chromosome 22 within TXNRD2 with P = 1.08×10−9.

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Figure 2. Meta-analysis Results Forest plots showing effect estimates for participating studies, as well as for the replication effort. Pooled estimates for odds ratios and 95% confidence intervals were calculated by fixed effects, inverse variance weighting meta-analysis. Individual dataset results are indicated by blue squares and summary values are indicated by black diamonds. (Top)
Association results for rs2745572 (FOXC1 region top SNP). (Middle) Association results for rs7137828 (ATXN2 region top SNP). (Bottom) Association results for rs35934224 (TXNRD2 region top SNP). For the overall NEIGHBORHOOD (NBH), the summary value
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for the population cohorts (POP; NHS/HPFS/WGHS) are presented separately from the case/control cohorts (CC; Iowa, OHTS (Ocular Hypertension Treatment Study), Marshfield, MEEI, NEIGHBOR). Results for the individual NBH datasets are shown in Supplementary Figure 4. Individual and summary results for Stage 2 (ANZ and ANZ+NBH) and Stage 3 cohorts (EPIC, GER, UK, BMES, SC) and summary points for all European ancestry (EU) datasets and all datasets (EU + SC) are shown. For rs7137828 replication could not be completed in SC due to rare minor allele frequency. Total sample size for rs2745572 and rs35934224 is 7,027 cases and 42,772 controls, and for rs7137828, 5,990 cases and 40,179 controls. Abbreviations: ANZ, ANZRAG;EPIC, European Prospective Investigation into Cancer-Norfolk Eye Study; GER, Germany; UK, United Kingdom; SC, Singapore Chinese; EU, European ancestry.

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Figure 3. ATXN2 and TXNRD2 are expressed in the retina and optic nerve head (A) Representative images of immunofluorescence using an anti-ATXN2 antibody shows ATXN2 (green) present in cells in the ganglion cell layer (arrows, upper panels) as well as punctate staining in the inner plexiform layer (arrowhead, right most upper panel). Only a low level of punctate staining was observed in the optic nerve head (arrowhead, lower panels). (B) Representative images of immunofluorescence using an anti-TXNRD2 antibody shows TXNRD2 (green) present in cells in the ganglion cell layer (arrows, upper panels) as well as significant punctate staining in the inner plexiform layer (arrowheads, right most
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panel). Significant staining was also observed in cells in the optic nerve head (lower panels) indicative of astrocytes that form pial columns (arrows, right most panel). Punctate staining was also observed in the optic nerve head (arrowheads, lower panels). For each antibody, at least 3 sections from 6 eyes were assessed. No staining (not even punctate staining) was observed in the no primary control tissue (data not shown). Blue=DAPI. In all rows, right most panels are boxed regions in center panels. Scale bars: Upper left and center panels in A and B = 20 μm; Lower left and center panels in A = 15 μm; Lower left center and panels in B = 25 μm; Right most panels in A and B = 5 μm.

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Table 1 Association and meta-analyses of the NEIGHBORHOOD and ANZRAG cohorts for the top-ranked loci.

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NEIGHBORHOOD

ANZRAG

(discovery, stage 1) (replication, stage 2) Meta-analysis NEIGHBORHOOD + ANZRAG

Chr SNP

Position A1 A2 Gene

OR P

OR P

OR P

Het I2

Het P

1 rs7518099 165736880 t c TMCO1

0.70 3.12E-13 0.71 8.02E-06 0.70

6.35E-18

4.1

0.40

4 rs11732100 7924690

t c AFAP1

0.85 3.93E-06 0.78 6.77E-06 0.83

1.98E-10

24.1

0.23

6 rs2745572 1548369

a g FOXC1

1.25 2.36E-09 1.18 6.46E-03 1.23

6.50E-11

0

0.58

9 rs7866783 22056359 a g CDKN2B-AS1 0.70 1.04E-23 0.67 2.92E-12 0.69

1.22E-34

39.2

0.11

9 rs2472493 107695848 a g ABCA1

0.83 1.24E-07 0.70 2.08E-10 0.79

2.44E-15

34

0.15

12 rs7137828 111932800 t c ATXN2

1.17 6.53E-06 1.22 4.36E-04 1.18

9.20E-09

3.1

0.41

14 rs33912345 60976537 a c SIX6

0.76 8.94E-15 0.78 6.21E-06 0.76

1.71E-19

0

0.87

17 rs9897123 10020501 t c GAS7

0.85 6.86E-06 0.79 1.45E-05 0.83

5.85E-10

0

0.69

22 rs35934224 19872645 t c TXNRD2

0.79 1.39E-06 0.74 2.01E-04 0.77

1.08E-09

0

0.83

Association results for the SNPs reaching genome-wide significance in the discovery cohort (rs2745572) as well as other top-ranked loci showing replication. Genomic position is based on build 37. A1 is the effect allele for both cohorts. Novel loci are highlighted in bold font. Abbreviations: NEIGHBORHOOD, National Eye Institute Glaucoma Human Genetics Collaboration Heritable Overall Operational Database; ANZRAG, Australian and New Zealand Registry of Advanced Glaucoma; Chr, chromosome; OR, odds ratio; Het I2, heterogeneity I2 index; Het P, p-for-heterogeneity; N/A, not available. Loci not previously reported are denoted in bold text.

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