Sex-specific disease association and genetic architecture of retinal vascular traits

Sex as a biological variable (SABV) remains underemphasized in biomedical research, despite its well-established impact on disease prevalence, progression, and genetic architecture. Here, we investigated sex differences in retinal vascular phenotypes, which are emerging as non-invasive biomarkers for ocular, cardiovascular, and neurodegenerative diseases. We used both interaction and sex-stratified analyses in disease association and genome-wide association studies (GWAS), including the X chromosome. Our analyses revealed sex-specific differences in associations between retinal traits, cardiometabolic risk factors, and disease outcomes. Several phenotypes showed prognostic value for mortality and cardiovascular endpoints, predominantly in one sex, illustrating the limitations of sex-agnostic analyses. Genetic analyses revealed differences in genetic architectures, with females exhibiting higher heritability and a greater number of associated loci, as well as sex-specific trait-gene associations. Notably, we report the first genetic association on the X chromosome for retinal vascular phenotypes. These findings suggest sex-differential genetic and environmental contributions to microvascular morphology, possibly reflecting divergent biological pathways and risk profiles. Our study underscores the necessity of integrating SABV and sex-aware approaches in genetic and prognostic research to advance precision medicine and improve tailored risk stratification.