Epibulbar osseous choristoma: Two case reports

INTRODUCTION

1.6 疗效标准 临床症候观察项目为：气促、发热、咳嗽。参照卫生部制定的《中药新药临床研究指导原则》和国家中医药管理局制定的《中医病证诊断疗效标准》及相关文献进行检索［5-6］，将主要症状按轻重程度分为4级，以3分制积分：正常为0分，轻度为1分，中度为2分，重度为3分。

CASE PRESENTATION

Chief complaints

Case 1: A 23-year-old woman with no obvious predisposing cause was found to have a soybean-sized mass above the outer sphere of her left eye and visited our hospital for more than 6 mo.

这里将工序也分为质检类和非质检类，分别用QualityProcedure和UnQualityProcedure表示为

Case 2: A 31-year-old man presented with a mass in the right upper eyelid persisting for 1 mo.

History of present illness

Case 1: The patient was asymptomatic with no ocular pain or diplopia as well as no history of eye trauma or surgery.

我先不知道对你称呼什么好些?一个青年可以在他敬爱的姑娘前面叫名字么?我想,你有少年人底理性和勇敢,你还是做我底弟弟罢。

History of past illness

Case 1 and Case 2: The patients had no past illness.

Personal and family history

Case 1 and Case 2: The patients had no history of familial diseases.

Physical examination

Case 1: Pre-procedure examination of the patient showed a pale-white nodule with a 5 mm diameter on the superior temporal bulbar conjunctiva of the left eye. It presented with a hard texture, mild hyperemia, poorly defined boundary, irregular shape, and no tenderness. The nodule was closely adhered to the substrate and could not be moved. There was no eye protrusion, and eye movement was normal (Figure 1). No abnormalities were found in the anterior and posterior segments.

Osseous choristomas are usually asymptomatic. Our patients were cured immediately after surgery, suggesting that surgical treatment is an effective strategy.

2.3 “uWS-MI”软件应用满意度 两名医师对“uWS-MI”界面友好性、时效性及操作便捷性，系统的稳定性和可靠性，系统数据管理的满意率均为100%。

加强对河道的清淤疏浚施工工作，让河道充分发挥其重要功能。重要作用。因此要加强对清淤疏浚技术的研究，对有关问题进行有效控制，保证各项生产活动顺利完成。在具体的工作中，应做好准备工作，掌握现场的实际情况，落实施工准备工作。还应做好安全生产工作，建立健全安全生产责任制，采取有效的安全防范措施，严格执行各项安全管理制度。有关部门负责人按照相关规定，组织人员进行河道清淤疏浚工作，保证河道顺通无阻，发挥河道在生产生活活动中的积极作用，促进经济建设事业不断发展壮大，提高人们的生活水平。

Choristoma is a rare, benign, congenital proliferative tumor[1], which is defined as normal tissue that stops migrating during embryonic development and is located in an abnormal position. Epibulbar choristoma normally occurs sporadically and develops alone, or it may be associated with a variety of syndromes[2], such as Goldenhar syndrome, epidermal nevus syndrome, and encephalo-cranio cutaneous lipomatosis.Ocular choristomas can be classified as dermoid, dermolipoma, complex choristoma(choristomas with more than one tissue type), and single-tissue choristoma, among which osseous and complex choristomas are the rarest. The prevalence of epibulbar choristoma ranges from 1/10000 to 3/10000[2] and can occur at multiple sites,predominantly in the cornea, rectus muscle, and conjunctiva. In this study, we reviewed myoblastoma cases treated at our hospital since 2010 and provided reports and detailed preoperative, intraoperative, and postoperative lesion images, including gross and pathological images, of two patients with osseous choristoma.

Case 1: Ultrasound biomicroscopy showed a strong elliptical echo in the superficial scleral layer under the bulbar conjunctiva at the superior temporal side, with a clear boundary, obscured inferior echo, and limited scope exploration (Figure 2). Computed tomography imaging indicated a massive calcification lesion of about 1.0 cm × 0.5 cm in the upper left part of the left eye conjunctiva, and the nodule appeared to be cartilaginous (Figure 3).

由图4可知，当加热温度为460 ℃时，薄壁铜管的延伸率随着保温时间的延长而变化不大，随保温时间延长存在轻微波动。当保温时间为30min时，延伸率为49%；保温时间为35min时，延伸率为51%；当保温时间增至40min时，延伸率稍有降低为50%；保温时间45min时，延伸率增至52%。但是，在保温时间为30min时，延伸率波动较大，为12%，这可能与该工艺条件下没有完全发生再结晶，存在部分变形组织有关，见图1（a）；在保温时间为35min、40min和45min时，铜管的延伸率波动仍较大，试样微观结构也存在部分变形组织，见图 1（b）、（c）、（d）。

可见，在上市公司治理中，只要法律对契约参与各方的欺骗行为的惩罚rx大于欺骗行为获得的剩余U2-U1,契约参与各方可能会选择诚信。相反，如果法治环境不好，对欺骗行为惩治的力度不够，对欺骗行为的惩罚rx小于欺骗获得的剩余U2-U1，契约参与各方的欺骗行为就可能发生。假设法院判决赔偿的概率r与法治水平q成正比，即r=a×q。

Histopathological evaluation confirmed osseous choristoma of the superficial sclera(fibrous connective tissue and fat surrounding the oblate neoplasm; hard as bone; and after decalcification, the tumor tissue was found to be mature bone tissue, with multiple Hastelloy tubes and annular bone plates, and no other soft tissue). The patient was diagnosed with epibulbar osseous choristoma and was cured after surgical excision (Figure 4).

Postoperative pathology confirmed osseous choristoma of the right upper eyelid. The tumor tissue was mainly composed of differentiated and mature bone and cartilage surrounded by a large number of proliferative collagen fibers.

We performed surgery to remove the neoplasm from the conjunctiva under local anesthesia; allo-scleral film was prepared to repair sclera. During the operation, the conjunctiva tissue on the surface was separated and the bone lesion with a diameter of 0.5 cm that was adhered to the scleral superficial tissue became visible. The neoplasm had a smooth surface and the sclera beneath was intact without pigment exposure, so it was then separated from the superficial sclera. Therefore, the capsule was sutured intermittently to reinforce the sclera. Postoperative suture removal was normal.

Case 2: The patient was asymptomatic without any ocular pain or diplopia and had no history of eye trauma or surgery.

The patient was cured after the surgery. The patient needs to be followed 1 mo after operation. If there is no discomfort, the patient will be followed every half a year.

OUTCOME AND FOLLOW-UP

Case 1

Treatment involved surgery during which one piece of solid tissue was excised. The resected tissue was red and nodular, with a wide base and no adhesion to the surrounding tissue, and also the neoplasm had a smooth surface. So it was then separated and capsule of the eyelid was sutured intermittently. Postoperative suture removal was normal.

Case 2

Surgery was successful, and the patient was cured. The patient needs to be followed 1 mo after operation. If there are discomfort symptoms, the patient should see a doctor at any time.

式中:F链min为驱动链轮的最小作用力;T电min为驱动电动机的最小转矩;r为履带驱动轮的半径;i为减速齿轮箱的减速比。

The concept of osseous choristoma was first proposed in 1863[5]. Its etiology is unknown and is related to abnormal gene expression and mesenchymal development.Trauma or infection stimulates the bone morphologic proteins, which leads to heterotopic ossification and accelerates the disease progression[3,4]. However, osseous choristoma does not have any malignant metastatic tendency and can be present at birth. It develops rapidly in early childhood and then gradually stabilizes and ceases growth[5], and it may eventually be detected due to symptoms such as foreign body sensation or conjunctival congestion in the later adolescent years.

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At present, there is no unified conclusion on the relationship between the occurrence and development of osseous choristoma and sex. Although it has been reported that young women tend to have a high incidence[4-7], the association with sex was not significant due to the small number of cases[2]. Additionally, osseous choristoma is observed more frequently in the right eye than in the left eye, and its sites are mainly distributed in the conjunctiva, sclera, and ophthalmic muscle, with most of them located in the fascia of the superior temporal quadrant[8-10], However,osseous choristoma occurring in the rectus muscle or eyelid is rare[6], and the frequency of these cases has not yet been statistically analyzed[1].

Since 2010, 296 cases of choristoma have been treated at our hospital, including 183 cases of dermoid cysts, 2 cases of osseous choristomas, 15 cases of osteoid lipomas, and 96 cases of dermoid tumors. The two cases of osseous choristoma, one female and one male patient, presented with a mass in the superficial sclera and eyelid, respectively.The prevalence of osseous choristoma in our hospital was 0.676%. Similar results were observed in a study conducted by Aldossary MM[2], in which among the 120 patients with myoblastoma of the ophthalmic surface, two had osteogenic myoblastoma, with a prevalence of 1.7%. Among the osseous choristoma cases in this study, one case was observed in a young woman, and it presented as a hard mass on the upper left temporal quadrant, which was in accordance with the previous reviews.CT imaging showed a high-density shadow, which was considered to be a dermoid tumor or lipoma, and a low-density focal area. Preoperative CT can be used to determine the properties and adhesion degree of the mass and the depth of the lesion resection. The treatment for osseous choristoma involves observation and surgical resection, with the surgical indications being foreign body sensation, irritative symptoms, and recurrent inflammation. In the study patients, the lesions were closely adhered to the sclera with poor activity, and surgical resection was performed for diagnostic and esthetic purposes[4].

The limitation of this case is that there are only two cases of epibulbar osseous choristoma, and the characteristics of osseous choristoma are not well summarized. In addition, the patients were not followed after surgery, so the postoperative outcome of the disease is unclear. Reviewing the previous literature, there are no large samples or long-term follow-up cases, so we suggest that the future study of osseous choristoma should increase the sample size to make statistical description of the primary sites,pathological features, prognosis and other aspects, so as to provide a clear diagnosis and outcome of the disease. Of course, special cases also deserve our attention.

CONCLUSION

We report two rare cases of osseous choristoma and their successful treatment. This study shows that clarifying the age, location, clinical manifestations, and CT findings of osseous choristoma can facilitate better diagnosis and guide further surgical treatment.