Sexual dimorphism shapes AAK trajectory in Pax6 deficiency mouse model with early immune activation, impaired innervation, and altered tears

Congenital aniridia often progresses to vision-threatening aniridia-associated keratopathy (AAK), yet when and how reduced PAX6 dosage destabilizes the ocular surface has remained unclear. Here we combine a conditional Pax6 haploinsufficient mouse with whole-mount imaging, functional assays, and sex-stratified corneal transcriptomics and tear-film proteomics to build an integrated, systems-level picture of disease initiation and progression. Pax6+/− pups show delayed eyelid opening, and from the moment of first environmental exposure the cornea is primed for pathology: leukocytes accumulate by postnatal week two and remain elevated thereafter, epithelial differentiation is mis-specified (KRT12 loss with central expansion of KRT14), and central proliferation is persistently depressed despite grossly normal wound closure. Sensory architecture and function are profoundly impaired, fine epithelial fibers and TRPM8+ terminals are depleted, and corneal sensitivity is reduced, while trigeminal ganglion transcriptomes change little, pointing to a cornea-intrinsic guidance/maintenance failure. Sex emerges as a potent modifier: in otherwise modestly dimorphic wild-type corneas, Pax6 haploinsufficiency drives male- and female-specific gene networks that converge on inflammation and extracellular-matrix remodeling but diverge in metabolic and innate-immune programs; tears mirror and likely reinforce these shifts, with female-biased hyposecretion at baseline and, after abrasion, a failure of Pax6+/− tears to mount the ribosome/translation and axon-guidance response seen in controls, instead exaggerating innate-immune and keratinization pathways. Together, the data recast AAK as a vicious cycle of epithelial dysmaturation, chronic inflammation, and neurotrophic failure amplified by sex-modulated lacrimal changes. By pinpointing early inflammatory priming, a cornea-encoded denervation mechanism, and modifiable tear-film deficits, this work nominates tractable entry points, tempering inflammation, restoring neurotrophic support and reinnervation, and normalizing tear quality, with direct translational relevance to preventing or slowing AAK.