Secondary Choroidal Osteoma in the Setting of Uveal Pathology: 4 Case Reports and Review

Abstract

Introduction

Choroidal osteoma is a rare benign tumor where mature bone replaces the choroid. Possible causes include inflammation, trauma, hormones, disorders of calcium metabolism, environmental factors, genetics, or osseous choristoma. This paper discusses 4 cases and literature regarding choroidal osteoma occurring concurrently with or secondary to uveal pathologies including uveitis and pachychoroid spectrum.

Case Presentations

In case 1, a 41-year-old man with central serous chorioretinopathy (CSCR) in both eyes (OU) developed a choroidal osteoma in the left eye (OS) 8 years after the initial visit. Type 1 macular neovascularization (MNV) developed 4 years later at age 53. In case 2, a 50-year-old woman with CSCR OU developed a choroidal osteoma OS 15 years after the initial visit. The lesion gradually enlarged over another 15 years of observation. In case 3, a 24-year-old woman with Vogt-Koyanagi-Harada disease treated with systemic corticosteroids for 6 months developed choroidal osteoma OU and type 2 MNV in the right eye (OD) 16 years after the initial visit. In case 4, a 55-year-old man with concurrent posterior scleritis and choroidal osteoma OS developed type 1 MNV 13 years after the initial visit. He had a history of unknown uveitis treated with high-dose corticosteroid therapy 21 years previously. In all 5 eyes, the presence of osseous tissue in the choriocapillaris and Sattler’s layer was confirmed by optical coherence tomography, B-mode ultrasound, or computed tomography. These lesions demonstrated observed growth in basal diameter and/or maturation process of bone tissue throughout the follow-up period.

Conclusion

We observed 5 eyes of four patients with choroidal osteoma in the choriocapillaris and Sattler’s layer of the choroid secondary to CSCR, Vogt-Koyanagi-Harada disease, or posterior scleritis over a long follow-up period of 12–30 years. Secondary choroidal osteoma, ectopic bone in the choroid, can result from the transformation of mesenchymal cells stimulated by osteoprogenitors, such as bone morphogenetic proteins. Secondary choroidal osteoma should be recognized as a rare long-term complication of uveal pathologies.

Plain Language Summary

We report 5 eyes of 4 patients with choroidal osteoma secondary to uveitis and pachychoroid spectrum such as central serous chorioretinopathy, Vogt-Koyanagi-Harada disease, and posterior scleritis before and after the development of the lesion. In general, choroidal osteoma is a rare benign tumor in which mature bone replaces the choroid. Possible causes include inflammation, trauma, female hormones, calcium metabolism, environmental factors, genetics, or osseous choristoma. However, the etiology and pathogenesis of choroidal osteoma are still unknown; few cases have been reported that ocular and adnexal inflammation is one of the factors leading to the development of choroidal osteoma. In our 12–30 years of clinical observation and literature review, we hypothesize that mesenchymal stromal cells such as pericytes and fibroblasts in the choroid, especially in the choriocapillaris and Sattler’s layer of the choroid, are transformed into ectopic bone by the interaction between intraocular inflammation and bone morphogenetic proteins. Secondary choroidal osteoma may occur as a rare long-term complication of uveitis and pachychoroid spectrum.

Introduction

Choroidal osteoma is a rare benign choroidal mass composed of mature cancellous bone that most often affects healthy teenagers or young adult females [1, 2]. The etiology of choroidal osteoma is unknown; however, several pathogeneses have been roughly divided into choristomatous, hereditary, hormonal, traumatic, and inflammatory [3, 4]. Inflammatory pathogenesis includes both pure ocular and adnexal inflammatory disorders, and microenvironmental inflammation secondary to degeneration, hemorrhage, and retinal detachment. The development of newly diagnosed choroidal osteoma after middle age may result from uveal pathologies. Herein, we report five eyes of 4 cases of secondary choroidal osteoma 8–16 years after the onset of uveitis and pachychoroid spectrum, and review relevant articles. This retrospective observational case series was approved by the Institutional Ethics Committee of the Fukushima Medical University and conducted in accordance with the tenets of the Declaration of Helsinki and the CARE guidelines [5].

Cases

Case 1

A 41-year-old man with central serous chorioretinopathy (CSCR) in both eyes (OU) appeared with subretinal fluid in the left eye (OS) 2 years after initial visit and spontaneously resolved within 1 year without recurrence. After 8 years observation from the initial visit at age 49 years, a flat orange-yellow choroidal lesion inferonasal to the fovea was noted OS measuring 4 × 3 × 0.3 mm where the retinal pigment epithelium detachments were seen previously. Swept-source optical coherence tomography (OCT) of the lesion showed horizontal and vertical tubules of vascular channels and a speckled appearance in the choriocapillaris and Sattler’s layer of the choroid suggestive of spongy trabecular or compact bone. Twelve years after the initial visit at age 53 years, an enlarging choroidal osteoma measuring 6 × 4 × 0.5 mm and subretinal hemorrhage were documented. Swept-source OCT showed type 1 macular neovascularization (MNV) and disruption of the retinal pigment epithelium and Bruch’s membrane with an intralesional horizontal line suggestive of bone lamellae in choroidal osteoma. The MNV was observed at the margin of choroidal osteoma adjacent to the barely preserved choriocapillaris (shown in Fig. 1).

Fig. 1.

A 41-year-old man with CSCR in both eyes (OU) who developed choroidal osteoma in the left eye (OS) 8 years after initial visit. a Color fundus photograph OS 2 years after initial visit developed subfoveal retinal detachment. There was no subretinal fluid OS when the diagnosis of typical CSCR OD was made at the initial visit. b Fluorescein angiography OS showed multiple retinal pigment epithelium detachment. c Swept-source optical coherence tomography (OCT) OS showed subfoveal serous retinal detachment and retinal pigment epithelium detachment. Note there was no choroidal mass in the thickened choroid. The subretinal fluid was resolved spontaneously within 1 year without recurrence after all. d Color fundus photograph OS 8 years after initial visit showed an orange-yellow subretinal lesion. e Swept-source OCT of green arrow in d showed the lesion located in the choriocapillaris and Sattler’s layer of the choroid with intralesional horizontal and vertical tubules suggestive of vascular channels, and speckled appearance suggestive of spongy trabecular or compact bone components. Note the choriocapillaris was replaced with the lesion and Haller’s layer of the choroid was kept intact. f Ultrasound showed calcified hyper-reflection with acoustic shadow. The findings of (d–f) confirmed the lesion choroidal osteoma. g Color fundus photograph OS 12 years after initial visit shows enlarging choroidal osteoma with MNV. h Swept-source OCT showed subretinal hemorrhage and type 1 MNV on the Bruch’s membrane which is partially disrupted. The MNV was located at the margin of choroidal osteoma adjacent to the barely preserved choriocapillaris. In the choroidal osteoma, obvious vascular channels in “picture (e)” disappeared and there is horizontal line suggestive of bone lamella.

Case 2

A 50-year-old female with spontaneous resolution of subretinal fluid in CSCR OU developed choroidal osteoma OS measuring 0.5 × 0.5 × 0.15 mm 15 years later. The lesion was located in the choriocapillaris and Sattler’s layer of the choroid. Documented growth measuring 2 × 2 × 0.25 mm was observed at an additional 5-year follow-up. Visual acuity decreased from 1.2 to 0.7 (Snellen equivalent: from 20/16 to 20/32) OS. Swept-source OCT showed a hyperreflective horizontal line suggestive of a cement line and a speckled appearance. Ultrasound showed calcified hyper-reflection with an acoustic shadow (shown in Fig. 2).

Fig. 2.

A 50-year-old female with CSCR in both eyes who developed choroidal osteoma in the left eye (OS) 15 years after initial visit. a Color fundus photograph OS 14 years after initial visit showed the parafoveal mottled RPE alteration in stable observation. b Time-domain optical coherence tomography (OCT) OS showed no evidence of presence of choroidal lesion. c Color fundus photograph OS 15 years after initial visit (at age 65 years) showed an orange-yellow subretinal lesion nasal to the fovea. d Spectral-domain OCT OS at green arrow in picture c showed that the choriocapillaris and Sattler’s layer of the choroid replaced with the lesion. Alteration of the retinal pigment epithelium and dilated vessels of the Haller’s layer of the choroid were observed. e Color fundus photograph OS 20 years after initial visit (at age 70) showed enlarged placoid orange-yellow choroidal lesion. f Late-phase fluorescein angiography OS showed dye-staining without leakage corresponding to orange-yellow choroidal lesion. The retinal pigment epithelium alteration superotemporal to optic disc did not show dye-leakage. g Swept-source OCT of horizontal section (green arrow in picture e) showed that full thickness of the choroid was replaced with the lesion. Intralesional OCT showed speckled appearance and hyperreflective horizontal line suggestive of cement line which confirm with choroidal osteoma.

Case 3

A 24-year-old female with Vogt-Koyanagi-Harada disease, treated with systemic corticosteroids for 6 months, developed choroidal osteoma OU 16 years later measuring 9 × 12 × 0.5 mm OD and 6 × 6 × 0.35 mm OS. There was MNV OD. Visual acuity was 0.7 OD and 1.2 OS (Snellen equivalent: 20/32 OD, 20/16 OS). Swept-source OCT showed a type 2 MNV and a hyper-reflective horizontal line, horizontal tubules, and speckled appearance. Swept-source OCT angiography confirmed intralesional blood flow consistent with that in the horizontal tubules of the vascular channels. Ultrasound showed calcified hyper-reflection with an acoustic shadow. This case was reported in another study [6] (shown in Fig. 3).

Fig. 3.

A 24-year-old female with Vogt-Koyanagi-Harada (VKH) disease treated with systemic corticosteroid for 6 months developed choroidal osteoma OU after 16 years from initial visit. a Color fundus photograph OU of initial visit showed multilobular exudative retinal detachment OU, and the optic disc hyperemia OS. Multimodal imaging and systemic evaluation confirmed VKH disease. b Color fundus photograph OU of 6 months later when systemic corticosteroid discontinued showed “sunset glow” fundus. No recurrence occurred after that. c Color fundus photograph OU after 16 years from initial visit showed choroidal osteoma OU. There was subretinal hemorrhage at the macula OD. d Swept source OCT OD (green arrow in c left) showed type 2 macular neovascularization (MNV) and hyper-reflective horizontal line, horizontal tubules and speckled appearance. The choriocapillaris and Sattler’s layer of the choroid were totally replaced with choroidal osteoma. Note the Haller’s layer of the choroid became thinner by being pushed by choroidal osteoma. e Swept source OCT OS (green arrow in c right) showed choroidal osteoma with minimal affecting of the outer retinal layers. Choroidal osteoma was located in the choriocapillaris and Sattler’s layer of the choroid and pushing Haller’s layer thinner. f Swept source OCT angiography OD of En-face and horizontal section confirmed type 2 MNV and intralesional blood flow consistent to horizontal tubules of the vascular channels. The MNV located the margin between choroidal osteoma and the choriocapillaris blood supply maintained.

Case 4

A 55-year-old man with painless posterior scleritis and choroidal osteoma simultaneously OS at the initial visit and developed MNV after 13 years. He had a history of unknown uveitis 21 years previously treated with high-dose systemic corticosteroids. Swept-source OCT showed undulated retinal pigment epithelium and thickened choroid with a speckled appearance. Ultrasound showed calcified hyper-reflection with acoustic shadow and thickening of the posterior sclera, but did not show a T-sign. Fluorescein angiography revealed optic disc leakage and late staining. Indocyanine green angiography showed early hyperfluorescence and late staining with marginal hypofluorescence. The diagnosis of choroidal osteoma secondary to posterior scleritis was made. Differential diagnoses, including choroidal hemangioma and choroidal metastasis, were ruled out because of the ultrasound findings and negative malignancy on systemic evaluation. Triamcinolone sub-Tenon injection was performed, and the subretinal fluid and undulation of retinal pigment epithelium were immediately resolved. After 13 years at age of 68 years, visual acuity was reduced from 1.2 to 0.5 (Snellen equivalent: from 20/16 to 20/40), and type 1 MNV developed OS. The choroidal osteoma was stable in size, but the intralesional OCT pattern was markedly changed to low density, suggestive of hypocellular marrow. The lesion is observed locating in the choriocapillaris and Sattler’s layer of the choroid and Haller’s layer was compressed thinner (shown in Fig. 4).

Fig. 4.

A 55-year-old man with posterior scleritis and choroidal osteoma simultaneously OS who developed MNV 13 years after initial visit. a Color fundus photograph OS showed orange-yellow choroidal lesion and choroidal striae with serous retinal detachment and hyperemia of the optic disc. The OD was otherwise normal. b Swept source optical coherence tomography (OCT) (green arrow in picture a) showed that choroidal lesion is located in the choriocapillaris and Sattler’s layer of the choroid with undulated surface of the retinal pigment epithelium and serous retinal detachment. Intralesional OCT showed speckled pattern without obvious vascular channels. c Ultrasound showed calcified reflection with acoustic shadow and thickened sclera (2 yellow arrows of A-mode ultrasound indicated scleral reflection) without “T-sign” of typical posterior scleritis. d Late phase fluorescein angiography showed dye-leakage from the optic disc and dye-staining corresponding to choroidal lesion. e Early phase indocyanine green angiography showed intralesional hyperfluorescence with dilated choroidal vessels of the Haller’s layer. f Late phase indocyanine green angiography showed intralesional dye-staining with a dark margin. Picture (a–f) confirmed choroidal osteoma secondary to posterior scleritis. Posterior scleritis was treated with a 20 mg single sub-Tenon’s capsule injection of triamcinolone acetonide. g Color fundus photograph OS post sub-Tenon triamcinolone acetonide (6 months after initial visit) showed resolution of both serous retinal detachment and hyperemia of the optic disc. h Enhanced depth OCT (green arrow in picture g) showed diffuse thickening of the choroid is resolved and the margin of choroidal osteoma clarified. Intralesional OCT became spongy appearance. i Color fundus photograph OS 13 years after initial visit showed subfoveal hemorrhage suggesting of MNV. j Spectral-domain OCT angiography (green arrow in picture i) showed type 1 MNV with subfoveal hemorrhage. The MNV located the margin between choroidal osteoma and the choriocapillaris blood supply maintained.

Discussion

Choroidal osteoma typically manifests as an orange-yellow placoid calcified lesion, replacing the full thickness of the choroid unilaterally in 79% and bilaterally in 21% of patients [7]. In one series of 74 patients, the tumor location was 84% juxtapapillary and 16% macular and the largest mean basal diameter was 8.2 mm [7]. Overlying retinal and retinal pigment epithelium changes vary widely, including changes in subretinal fluid (28%), subretinal hemorrhage (18%), subretinal fibrosis (27%), retinal pigment epithelium hyperplasia (74%), and choroidal neovascularization (19%) [7].

Three types of cells contribute to bone homeostasis including osteoblasts, osteoclasts, and osteocytes [8]. Osteoblasts are bone-forming cells; osteoclasts resorb or break down bone; and osteocytes are mature bone cells. A balance between osteoblasts and osteoclasts maintains bone tissue, which makes the findings widely variable and diagnosis difficult. Numbers of differential diagnoses are known including choroidal metastasis, amelanotic choroidal melanoma, amelanotic choroidal nevus, choroidal lymphoma, leukemia, retinoblastoma, circumscribed choroidal hemangioma, choroidal neurilemoma, choroidal leiomyoma, posterior scleritis, choroidal granuloma, solitary idiopathic choroiditis, age-related macular degeneration, Best’s vitelliform macular dystrophy, organized subretinal hemorrhage, CSCR, idiopathic sclerochoroidal calcification, metastatic calcification, dystrophic calcification [3], and recently advocated clinical entities of inner choroidal fibrosis [9], serous maculopathy due to aspecific choroidopathy (SMACH) [10], stellate multiform amelanotic choroidopathy (SMACH) [11]. In cases of atypical choroidal osteoma, the most reliable diagnostic findings of choroidal osteomas are intralesional OCT suggestive of a compact bone or sponge bone [12–15], ultrasound and computed tomographic findings indicating the presence of calcification [2, 16]. In our 4 cases, OCT confirmed the presence of bony tissue and ultrasound confirmed calcification. The most frequently reported pathogenesis of newly arising choroidal osteomas in middle-aged individuals is ocular and adnexal inflammation. There are not many reports (Table 1) on the possible induction of ocular and adnexal disease, including histiocytic tumor antedate onset of secondary choroidal osteoma [6, 17–30].

Table 1.

Literature discussing the concern for a relationship between ocular and adnexal disease and the development of secondary choroidal osteoma

Primary disease	Age at diagnosis, years	Sex	Affected eye	Interval before onset, years	Fundus exam before diagnosis	Associate choroidal neovascularization	Reference
Branch retinal vein occlusion	62	M	OS	8	yes	yes	Adhi et al. [17], 2013
CSCR	48	M	OS	unknown	no	no	Erol et al. [18], 2015
Stargardt disease	16	F	OS	unknown	no	yes	Figueira et al. [19], 2007
Retinitis pigmentosa	35	F	OD	unknown	no	no	Browning [20], 2003
Behcet disease	36	F	OU	2	yes	no	Casaroli-Marano et al. [21], 2010
Vogt-Koyanagi-Harada disease	30	F	OU	10	yes	no	Ozawa et al. [22], 2019
Posterior scleritis	14	F	OU	1	no	no	Ng et al. [23], 2022
Posterior scleritis	17	F	OS	5	yes	no	Trimble and Schatz [24], 1983
Posterior scleritis	26	M	OS	10	yes	no	Sun et al. [25], 2024
Pposterior scleritis (IgG4 related)	12	M	OD	3	yes	no	Nair et al. [26], 2020
Orbital multifocal fibrosclerosis (IgG4 related)	23	F	OU	4	yes	no	Takkar et al. [27], 2018
Orbital inflammatory pseudotumor	11	F	OD	1	yes	yes	Katz and Gass [28], 1983
Langerhans cell histiocytosis (histiocytosis X)	11	M	OU	11	no	no	Kline et al. [29], 1982
Langerhans cell histiocytosis	24	M	OU	22	no	no	Azadi et al. [30], 2019
CSCR (case 1)	49	M	OS	8	yes	yes	Current paper
CSCR (case 2)	65	F	OS	15	yes	no	Current paper
Vogt-Koyanagi-Harada disease (case 3)	40	F	OU	16	yes	yes	Current paper, Mukai et al. [6], 2024
Posterior scleritis (case 4)	55	M	OS	21	no	yes	Current paper

In this series, 3 out of 4 cases (case 1–3) had a long follow-up period before and after newly arising secondary choroidal osteoma. Cases 1 and 2 showed the lesion at the Sattler’s layer of the choroid affecting the choriocapillaris and retinal pigment epithelium in the area where subretinal fluid and retinal pigment epithelium detachment were observed in previous CSCR. CSCR is a pachychoroid spectrum with multiple factors, including venous congestion, inflammation, ischemia, and changes in hormones and biochemical milieu, such as catecholamine, corticosteroids, or inflammatory cytokines [31]. Choroidal osteomas secondary to CSCR can occur in the context of the pachychoroid, resulting in presumed chronic inflammation in the microenvironment. The recently advocated clinical entities of inner choroidal fibrosis [9] and SMACHs [10, 11] are the late degenerative changes of CSCR, with a clinical appearance similar to that of choroidal osteoma; however, these lesions are ill-defined without evidence of either calcification or growth. There are only reports discussing the cause-effect relationship between CSCR and choroidal osteoma [18], however, no pictures before the occurrence of choroidal osteoma are provided.

Case 3 was a case of Vogt-Koyanagi-Harada disease causing secondary choroidal osteoma OU. The lesion is likely to be almost full thickness of the choroid; however, it severely affects the retinal pigment epithelium, choriocapillaris, and thickened Sattler’s layer, replaced by osteoma, compressing the Haller’s layer of the choroid.

Case 4 had a history of unknown uveitis treated with high-dose systemic corticosteroids 21 years previously; simultaneous existence of a spongy osteoid component in the choroid and posterior scleritis was seen in our initial visit. Although our differential diagnosis was ossified choroidal hemangioma, the excellent OCT light transmission and clinical course did not match the ossified choroidal hemangioma. 13 years’ follow-up confirms reduction of lesion localization in the Sattler’s layer of the choroid, thinning of the choroid around the lesion, and development of type 1 MNV according to the resolution of posterior scleritis.

Of the five eyes with choroidal osteoma in the four current cases, three developed MNV. Our observation is that the mechanism of MNV development results from the ischemic condition of the choriocapillaris because they appeared on Bruch’s membrane at the border between the area the choriocapillaris/retinal pigment epithelium severely affected and the area blood flow was preserved. However, there is a unique paper that surgically removed the subfoveal neovascular membrane arising from choroidal osteoma containing osteoclasts, suggesting possible extension of the osteoma itself [32]. Choroidal osteoma-associated neovascular membranes variably occur on the surface of the lesion or type 1 [33, 34], type 2 [35] or polypoidal vasculopathy [36] at the decalcified location [7]. The mechanisms underlying MNV development may vary.

Of the five eyes with secondary choroidal osteoma, lesions were observed in the choriocapillaris and Sattler’s layer of the choroid, especially in the early phase of occurrence (cases 1 and 2). Gass et al. [1] reported that histopathological findings of an enucleated eye showed choroidal osteoma composed of mature bone arising in the inner third of the choroid with hypocellular marrow space and thin-walled blood vessels communicating with a rich capillary network lying beneath Bruch’s membrane. Through a long follow-up of case series, we observed the early phase of osteogenesis developing in the choriocapillaris and Sattler’s layer of the choroid, which may reconfirm the histopathological result by Gass et al. [1].

Secondary choroidal osteoma, ectopic bone formation in the choroid, can be caused by multiple factors such as chronic inflammatory processes, bone morphogenetic proteins (BMPs), growth factors, pericytes, fibroblasts, and the presence of mesenchymal stem cells [37, 38]. Both pericytes [39, 40] and fibroblasts [41, 42] have been demonstrated in many recent studies to be key populations in ectopic ossification, and at the same time, they have also been suggested to be potential targets for treatment [41, 43]. BMPs are morpho-functional cytokines classified into a subfamily in the transforming growth factor beta superfamily, and multiple BMPs (BMP-2, 6, 7, and 9) have the potential to promote the transformation of mesenchymal cells into osseous elements [44, 45]. BMP-7 is a distinct osteoprogenitor that stimulates ectopic bone formation [46]. In contrast to over 94% of retinal capillaries, 11% of the choriocapillaris contain pericytes [47, 48]. The choroid comprises blood vessels, supporting collagenous and elastic connective tissue, and an intrinsic population of cells such as melanocytes, fibroblasts, pericytes, smooth muscle cells, choroidal neurons, and immunocompetent cells [49]. Therefore, the choroid, especially Sattler’s layer, which is rich in intercellular matrix, can be a source of mesenchymal stromal cells that have progenitor cell properties, including the capacity for mesenchymal differentiation when encountered under osteogenic, adipogenic, and chondrogenic conditions [50]. This paper addresses the pathogenesis of secondary choroidal osteoma in clinical aspects consisting with small case series, it needs to be clarified with further case accumulation and experimental study.

Conclusion

In conclusion, we observed five eyes in 4 patients with choroidal osteoma secondary to uveal pathologies including CSCR, Vogt-Koyanagi-Harada disease, and posterior scleritis with a long follow-up of 12–30 years. Secondary choroidal osteomas located in the choriocapillaris and Sattler’s layer of the choroid and affect Bruch’s membrane and retinal pigment epithelium over time, resulting in the development of type 1 and 2 MNV in three eyes. By reviewing the literature, we hypothesized that mesenchymal stromal cells such as pericytes and fibroblasts in the choroid transform into ectopic bone by the interaction between intraocular inflammation and bone morphogenetic proteins (BMPs). Extended follow-up beyond standard may detect secondary choroidal osteoma as a rare, long-standing complication of uveitis and pachychoroid spectrum. The CARE Checklist has been completed by the authors for this case series, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000548250).

Statement of Ethics

This study was performed in accordance with the Declaration of Helsinki. This human study was approved by Ethics Committee of Fukushima Medical University – approval: 2020-91. All adult participants provided written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for publication of the details of their medical case and any accompanying images.

Conflict of Interest Statement

The authors have no financial interests, conflicts of interests, or disclosures related to this study.

Funding Sources

There are no funding sources to declare.

Author Contributions

M.F.: research design, diagnosis and patient management, writing, editing, and revising the manuscript. K.T.: diagnosis and patient management, editing, and revising the manuscript. S.M.: diagnosis and patient management and editing and revising the manuscript. R.M.: diagnosis and patient management, writing, editing, and revising the manuscript. J.A.S.: diagnosis, editing, and revising the manuscript. C.L.S.: diagnosis, editing, and revising the manuscript. T.S.: research design, writing, editing, and revising the manuscript, and supervision.

Funding Statement

There are no funding sources to declare.

Data Availability Statement

All data generated or analyzed during this study are included in this article and its online supplementary material. Further inquiries can be directed to the corresponding author.