BACKGROUND: Keratoconus (KC) is an asymmetrical bilateral corneal ectasia, of which the pathogenesis is unknown. Moreover, genetic factors play an important role. We reported ophthalmic findings in a Chinese family with monozygotic twins with KC to describe the clinical features and identify genetic variants. METHODS: Comprehensive ophthalmic clinical assessments and examinations, including history, slit-lamp biomicroscopy, best-corrected visual acuity, corneal topography, anterior segment optical coherence tomography, and corneal biomechanics, were carried out on the twins and their parents. Whole-genome sequencing (WGS) was performed to identify variants in this family. SIFT, PolyPhen2, MutationTaster, and CADD were used to predict the effect of amino acid substitutions on the affected protein. RESULTS: The twins presented typical KC features. However, their mother did not meet the criteria for a KC diagnosis but exhibited KC subclinical manifestations. After screening, 12 potentially pathogenic variants in 10 genes were identified in both twins and emerged as candidate variants for this family. These genes included 1 previously reported KC-associated variant (ZNF469, c.4384 G>
A)
8 variants in 6 KC-associated genes (GRHPR, c.337 G>
A, c.862_863del
COL6A1, c.920 G>
A
FLG, c.8753C>
G
HSPG2, c.9503C>
T
KRT82, c.1306 G>
A
SCN9A, c.5702_5706del, c.641 G>
A)
and 3 variants in 3 non-KC-associated genes (PDE6G, c.6C>
A
HAL, c.1724C>
T
AGBL1, c.2381 G>
A). CONCLUSIONS: The accumulation of these potentially pathogenic variants in twins may have caused KC in these twins. These results expand the spectrum of KC candidate variants and provide a basis for further studies on KC.