Case Report Epibulbar Osseous Choristomadownloads.hindawi.com/journals/criopm/2014/292619.pdf ·...

Case ReportEpibulbar Osseous Choristoma

Tolga Bicer1 and Hasan Soylemez2

1Ophthalmology Department, Diskapi Yildirim Beyazit Education and Research Hospital, Irfan Bastug Street, Diskapi,06330 Ankara, Turkey2Radiology Department, Unye Cakirtepe Hospital, Ataturk Mah. Tepeyolu Street No. 43, 52300 Ordu, Turkey

Correspondence should be addressed to Tolga Bicer; drtolgabicer@yahoo.com

Received 21 September 2014; Accepted 24 November 2014; Published 15 December 2014

Academic Editor: Alexander A. Bialasiewicz

Copyright © 2014 T. Bicer and H. Soylemez. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The topic of this case report is a rare subconjuctival osseous choristoma that corresponded to the left lateral sunconjunctivaand canthus. A 20-year-old man was asymptomatic when he arrived for the examination. His full ophthalmic examination wasnormal. Orbital computerized tomography was concordant with osseous lesion. Osseous choristomas are the rarest forms of ocularchoristomas, they are usually being defined as sporadic, and they are found at the superior temporal region of the episclera. Inour case, choristoma was in the lateral canthus of the left eye. We had administered surgical excision by reason of the patient’scosmetic requirement.We had noted that the lesion was adherent to conjunctiva but not to the sclera and themuscles. After surgicaltreatment, we saw mature heterotrophic osseous tissue in subconjunctival area and Haversian canals in compact bone tissue.

1. Introduction

Osseous choristomas are solid nodules, composed of mature,compact bone together with pilosebaceous units and hairfollicles. The topic of this case report is a rare osseous choris-toma that localized to the left lateral subconjunctiva, in whichunderlying sclera was not involved.

2. Case Report

A20-year-oldmanwas asymptomatic when he arrived for theexamination. In his medical history, he had a swelling on theleft corner of the left eye since his birth. He had no medicalproblems or trauma. He has never used alcohol; however, hewas smoking. His family thought that there was growth inthe lesion compared to the past. His visual acuity was 20/20.External examination of the right eye, anterior segment, andfundus examination of both eyes were normal.

The swelling was approximately 6.0mm × 6.0mm sub-conjunctival lesion on the left eye (Figure 1). It was a mobilemass going towards left lateral canthus, so that we thoughtit did not involve the underlying sclera. The swelling wasfirm and had hair follicles and vascularization on some

areas. Orbital computerized tomography was concordantwith osseous lesion (Figure 2).

Informed consent was obtained for the local anesthesia.Intraoperatively, the lesion was adherent to conjunctivabut not to the sclera and the muscles. The mass and theadherent conjunctivawere removed totally and the remainingconjunctiva tissue was stitched edge to edge. The swellingwas sent to histopathology immediately. Its result was epis-cleral osseous choristoma. Histopathologically, mature het-erotrophic osseous tissue was seen in subconjunctival area(Figure 3(a)).

3. Discussion

The term heterotopia (choristoma) is applied to microscopi-cally normal cells or tissues that are present in abnormal loca-tions. Examples of heterotopias include the rest of pancreatictissue found in the wall of the stomach or small intestine; asmall mass of adrenal cells found in the kidney, lungs, ovariesor elsewhere; or as in our case a mass of mature bone cellsfound under conjunctiva. It was first described by von Graefeas epibulbar osteoma [1, 2]. Ocular choristomas consisted of

Hindawi Publishing CorporationCase Reports in Ophthalmological MedicineVolume 2014, Article ID 292619, 3 pageshttp://dx.doi.org/10.1155/2014/292619

2 Case Reports in Ophthalmological Medicine

Figure 1: Subconjunctival lesion of the left eye (arrow).

Figure 2: Episcleral osseous choristoma on the lateral canthus of lefteye in computed tomography (arrow).

limbal dermoids, dermolipomas, complex choristomas, andosseous choristomas [3, 4].

In a 302-periorbital-tumor-case series, Elsas and Greenreported that 33% were choristomas, 29% were nevi, 11%were epidermal inclusion cysts, and 7% were papillomasin children. In the study, there were approximately 100choristomas; 58% of the choristomas were dermoid cysts,30%were dermolipomas, 6%were dermoid choristomas, and6% were teratomas [5].

The other reported localizations of extraocular choris-tomas were the oral cavity, usually in the tongue and also atother soft tissues of the head and neck [6].

The differential diagnosis includes epibulbar dermoids,epithelial inclusion cysts, limbal dermoids, prolapsed orbitalfat, papillomas, dermolipomas, and complex choristomas.

Osseous choristomas are the rarest forms of ocularchoristomas, they are usually being defined as sporadic, andthey are found at the superior temporal region of the episclera[4, 7]. Gayre et al. analyzed 51 cases of epibulbar osseouschoristomas and reported that 69% were female, 76% werein the right eye, and 74% had superotemporal localizationpreponderance [8]. Our case was 20-year-old male whosechoristoma was in the lateral subconjunctiva of his left eye.His gender and the affected eye were a different propertywhen compared with general literature.

In literature, there are very few pieces of informationabout hair follicles localized in the conjunctiva, overlying thechoristoma. In our case there were multiple hair follicles,

Figure 3: (a) Conjunctival epithelium (thin arrow) and het-erotrophic osseous tissue (left thick arrow) (HEx20); (b) osseoustissue-like compact bone and Haversian canals (HEx200) (rightthick arrow).

localized only in the overlying conjunctiva of the choristoma.Intraoperatively, the mass and the adherent overlying con-junctiva were excised and the rest of the conjunctival tissuewas stitched edge to edge.

The lesions are generally adherent to extraocular musclesheath, overlying conjunctiva or underlying sclera [9]. Wehad noted that the lesion was adherent to overlying conjunc-tiva but not to the sclera and the muscles. It was a differentproperty when compared with the general literature.

Surgical excision is needed when choristomas get symp-tomatic and also for cosmetic reasons, although choristomasare stable lesions and usually grow slowly [3, 4, 7, 8]. We hadadministered surgical excision for the reason of the patient’scosmetic requirement.

Histopathological images of the choristomas showmature compact bone, surrounded by fibrous connectivetissue [4, 7]. Typically lesions contain Haversian canals.Although there are a few case reports describing the presenceof hematopoietic tissue, no bonemarrow tissue has been seen

Case Reports in Ophthalmological Medicine 3

[8]. In our case, mature heterotrophic osseous tissue was seenin subconjunctival area (Figure 3(a)) and Haversian canalsin compact bone tissue (Figure 3(b)) which was typical forthis type of choristoma.

In our case, the choristoma was localized in the left eye,was not adherent to the underlying sclera and the muscles,and had hair follicles, contrary to general literature articles.As a result, rarely seen episcleral osseous choristoma shouldbe consideredwhen amass is seen in any eye, gender, and age,especially localized superotemporally.

Consent

Thepatient has consented to the submission of the case reportfor submission to the journal.

Conflict of Interests

The authors have no commercial associations or financialdisclosures that might pose a conflict of interests with infor-mation presented in this paper. No granting or sponsoringagencies funded this paper.

References

[1] A. Von Graefe, “Tumor in submucosen gewebe lid-bindehautvon eigenthumlicher, beschaffenheit,” Klin Monatsbl Augen-heilkd, pp. 1–23, 1863.

[2] M. Boniuk and L. E. Zimmerman, “Epibulbar osteoma (episcle-ral osseous choristoma),” American Journal of Ophthalmology,vol. 53, no. 2, pp. 290–296, 1962.

[3] E. Hadjadj, J. Conrath, and D. Denis, “Bilateral osseous choris-toma,” Journal of Pediatric Ophthalmology and Strabismus, vol.36, no. 6, pp. 347–348, 1999.

[4] B. J. Kim and M. Kazim, “Bilateral symmetrical epibulbarosseous choristoma,” Ophthalmology, vol. 113, no. 3, pp. 456–458, 2006.

[5] F. J. Elsas and W. R. Green, “Epibulbar tumors in childhood,”American Journal of Ophthalmology, vol. 79, no. 6, pp. 1001–1007,1975.

[6] A. C. B. R. Johann, B. G. Garcia, T. R. Nacif, J. B. de Freitas, M.A. V. do Carmo, and R. A. Mesquita, “Submandibular osseouschoristoma,” Journal of Cranio-Maxillofacial Surgery, vol. 34, no.1, pp. 57–59, 2006.

[7] J. H.Moon,D. Y. Yoon, C. S. Choi et al., “Bilateral ocular osseouschoristomas,” Pediatric Radiology, vol. 35, no. 11, pp. 1145–1146,2005.

[8] G. S. Gayre, A. D. Proia, and J. J. Dutton, “Epibulbar osseouschoristoma: case report and review of the literature,” Oph-thalmic Surgery and Lasers, vol. 33, no. 5, pp. 410–415, 2002.

[9] D. Gogi and R. Sherwani, “Adherent episcleral osseous choris-toma,” Asian Journal of Ophthalmology, vol. 8, no. 1, pp. 35–36,2006.

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