Bee and wasp stings of the eye. Retained intralenticular wasp sting: A case report

Endothelial dysfunction of the cornea after exposure to sprayed venom from hornets

PURPOSE

Ocular injuries due to Hymenoptera venom are uncommon and most injuries occur on the ocular surface. We reported two rare cases of corneal endothelial damage caused by hornet venom that was sprayed, not injected, through stinging in the eye.

OBSERVATIONS

Case 1: A 57-year-old male patient was injured when a hornet sprayed venom into his left eye. He was referred to our hospital because the edoema and epithelial erosion of the cornea persisted. The patient presented with bullous keratopathy, asymmetrical iris atrophy, irreversible mydriasis, and glaucoma. His cataract progressed, and his best-corrected visual acuity was 0.03. Cataract surgery was performed after anti-inflammatory treatment with steroids, and Descemet-stripping automated endothelial keratoplasty was performed 6 months later. The patient recovered well postoperatively: his best-corrected visual acuity improved to 1.0 and he continued his glaucoma treatment. Case 2: A 75-year-old male patient had damage to his corneal epithelium, severe conjunctivitis, and conjunctival edoema when sprayed hornet venom entered his left eye. At initial presentation, the corneal endothelial cell density had decreased to 1042 cells/mm2. The conjunctival sac was washed, and steroid and topical antibacterial instillations were administered. His best-corrected visual acuity improved from 0.07 at the initial visit to 0.5. However, the corneal opacification and glaucoma persisted, and 3 months later the corneal endothelial cell density decreased to 846 cells/mm2.

CONCLUSIONS AND IMPORTANCE

Corneal injuries caused by sprayed hornet venom are rare; however, they can cause intense anterior chamber inflammation and severe, irreversible corneal endothelial damage. In such cases, prompt initial treatment, the administration of adequate anti-inflammatory medication, and careful evaluation of the corneal endothelium are required.

Management of bulbar conjunctival injury by honeybee sting: A case report of a retained honeybee stinger

PURPOSE

To report a rare case of a bee sting to the conjunctiva of the eye in which the stinger remains in the subconjunctival space.

OBSERVATIONS

We present the case of a fifty-five-year-old male who sustained a honeybee sting to the conjunctiva of his left eye after which some stinger remnants were left in place. He was initially treated with topical antibiotics, and topical and systemic steroids were added the next day. His visual acuity recovered fully with this regimen, despite later visualization of a retained bee stinger in the subconjunctival space.

CONCLUSION AND IMPORTANCE

Our experience suggests that though immediate removal of a stinger in the case of a bee sting to the eye is likely the safest approach, the long-term persistence of a bee stinger in the conjunctiva may not pose a threat to visual acuity and ocular health.

Visual Loss Caused by Central Retinal Artery Occlusion After Bee Sting: A Case Report

A bee sting can lead to an extremely rare case of visual loss caused by central retinal artery occlusion (CRAO). In this study, we report a 66-year-old healthy woman who was referred to our Eye Center because of visual loss, which had occurred after bee sting 2 days earlier. The visual acuity was no light perception (NLP). Examination revealed left eyelid edema, conjunctiva congestion, a 6-mm fixed pupil, scattered retinal hemorrhage, and white-appearing ischemic retina with one small area of the normal-appearing retina temporal to the optic disk. Fundus fluorescein angiography revealed CRAO with one cilioretinal artery sparing. Her systemic workup revealed hypersensitivity, hypercoagulable state, myocardial damage, and hepatic damage. After topical and systemic treatments, the visual acuity was still NLP with improved systemic workup. In brief, CRAO may occur after bee sting, and visual acuity should be monitored for early diagnosis.

Corneal bee sting in a Bengal cat

Case summary

A 6-month-old female Bengal cat was referred for a suspected vegetal foreign body (FB) in the mid-stroma of the right cornea. A small dark linear FB was identified in the dorsal aspect of the cornea, with associated cell infiltrate. Ophthalmic examination was otherwise normal, with no inflammatory reaction of the anterior uvea, and no abnormalities of the lens or fundus. Surgical removal was performed under general anesthesia. The FB, as observed under an optic microscope, was a worker bee stinger without the venom sac. Medical treatment consisted of topical and systemic antibiotics and steroids, and topical administration of atropine. Follow-up was uneventful.

Relevance and novel information

Ocular bee stings have been described in humans, with several consequences ranging from mild conjunctivitis to severe lesions affecting the cornea, iris, lens and retina. Most severely affected cases have been observed when the venom sac was found with the stinger, with a likely greater amount of venom being delivered into the ocular structures. The relatively benign presentation of this case was probably due to the lack of the venom sac within the bee sting. To our knowledge, this is the first documented case of a corneal bee sting in a cat.

Ocular Injury Caused by the Sprayed Venom of the Asian Giant Hornet (Vespa mandarinia)

This report presents the details of a case of sight-threatening injury in the right eye of a 77-year-old man which was caused by the venom of the Asian giant hornet (Vespa mandarinia). The patient was not stung, rather the venom was sprayed into his eye. Although the injured eye was washed as a first aid treatment, persistent corneal defect, corneal endothelial decompensation, iris atrophy, pupil dilation, and mature cataract were observed and a hand movement visual acuity was recorded 8 weeks after the injury. Since a slight a-wave was detected in his electroretinogram (ERG) result after the corneal epithelial defect had healed, we performed cataract surgery and Descemet stripping automated endothelial keratoplasty (DSAEK). After the DSAEK, the cornea of the right eye became clearer; however, the visual acuity of his right eye did not improve. Fundus examination revealed branch retinal artery occlusion but no optic disc atrophy. ERG showed that the a-wave amplitude of the injured eye recorded after the surgery was almost half of that of the fellow eye. The iris atrophy and mature cataract show that the sprayed Vespa venom of the Asian giant hornet can permeate into the intraocular area even without stinging. Whether the venom directly affects retinal function is unclear, but the decreased a-wave of the injured eye shows that the venom caused damage of retinal function in some way. Irrigation of the anterior chamber as well as eye washing is needed as a first aid treatment in similar cases.

A Case of Conjunctival Bee Sting Injury with Review of the Literature on Ocular Bee Stings

BACKGROUND Ocular bee stings have been rarely described in the literature, and their management is controversial. A case of conjunctival bee sting with retention of the stinger for 48 hours is presented with a review of the literature on the complications and management of ocular bee sting injury. CASE REPORT A 22-year-old beekeeper presented to the Emergency Department with mild symptoms from a conjunctival bee sting that he had received 48 hours previously. The stinger was removed in the Emergency Department, and topical antibiotic and anti-inflammatory treatment with corticosteroid were given. There were no complications in this case. However, review of the literature has shown that although the outcome from ocular bee stings can be mild, as in this case, ocular bee stings can result in severe visual symptoms that require amniotic membrane transplant (AMT). Management commonly includes removal of the stinger and both topical and systemic treatment with corticosteroids. The main complications include cataracts, inflammation of the anterior chamber, optic neuropathies, and changes in ocular pressure. CONCLUSIONS Ocular bee stings have been rarely described in the literature, and the management remains controversial. As this case has shown, removal of the stinger and the use of topical treatment with antibiotics and corticosteroids can prevent potentially serious complications that may affect vision. Early and regular follow-up with ocular imaging may be required when symptoms persist.

Hymenoptera insect stings: Ocular manifestations and management

PURPOSE

To describe the ocular findings and management of Hymenoptera insect stings.

METHODS

We treated and followed 8 patients with ocular Hymenoptera stings. All patients were admitted through emergencies and hospitalized at the Hedi Rays eye institute in Tunis.

RESULTS

The site of the sting was the cornea in 5 cases, limbus in one case, conjunctiva in one case and upper lid in the last case. Retained stingers were objectified in 4 cases. Immediate surgical extraction carried out in all cases. We also followed one case of post-sting Adie's syndrome and one case of retrobulbar optic neuritis. The sting was conjunctival in one case and palpebral in the other case. Corticosteroids were ineffective in these two cases.

CONCLUSION

Ocular Hymenoptera stings are rare environmental accidents. They may cause various severe ocular complications. Early management, adapted to the clinical manifestations, is the key to a good outcome.

Predicting visual function after an ocular bee sting

PURPOSE

To report a case of toxic optic neuropathy caused by an ocular bee sting.

METHODS

Case report and literature review.

RESULTS

A 44-year-old female presented with no light perception vision 2 days after a corneal bee sting in her right eye. She was found to have diffuse cornea edema with overlying epithelial defect and a pinpoint penetrating laceration at 6 o'clock. There was an intense green color to the cornea. The pupil was fixed and dilated with an afferent pupillary defect. A small hyphema was seen, and a dense white cataract had formed. A diagnosis of toxic endophthalmitis with associated toxic optic neuropathy was made. The patient underwent pars plana vitrectomy and lensectomy with anterior chamber washout. She was also placed on systemic broad-spectrum antibiotics. She had noted clinical improvement over the course of her hospitalization and was discharged with light perception vision. A corneal opacity precluded viewing of the fundus. We utilized ganzfeld electroretinography and flash visual evoked potentials (2 and 10 Hz) to assess the visual function. Both tests were normal and predicted improvement following restorative surgery. She underwent a secondary lens implantation with penetrating keratoplasty 7 months later. This was followed by an epiretinal membrane peel 1 year after the bee sting. Her best corrected visual acuity improved to 20/80.

CONCLUSION

Toxic endophthalmitis and toxic optic neuropathy can be complications of ocular bee sting. We discuss the management of this rare occurrence and the role of electroretinographic testing and visual evoked potentials in predicting visual outcome.

Management of Corneal Bee Sting Injuries

PURPOSE

To review the management of keratitis after corneal bee stings and to report a case of deep stromal corneal infiltrate secondary to a retained bee stinger managed conservatively in a patient who presented three days after unsanitary manipulation of the stinger apparatus.

METHODS

Case report and review of literature.

RESULTS

A 57-year-old male beekeeper was evaluated for pain, blurry vision, and photosensitivity after a corneal bee sting. Of note, the venom sac had been removed with dirty tweezers three days prior to his visit. On exam, a focal infiltrate with diffuse edema was seen surrounding a retained bee stinger in the peripheral cornea. Trace cells in the anterior chamber were also noted. Based on a high suspicion for infectious keratitis, a conservative treatment strategy was elected. Administration of broad-spectrum topical antibiotics with concomitant abstention of corticosteroids led to rapid resolution of the symptoms. Over 16 months of follow-up, the stinger has remained in situ without migration and the patient has maintained 20/20 visual acuity without complications. There is debate on the preferred method for the management of corneal injury secondary to bee stings, especially when it is associated with a retained stinger. We herein present our findings in our appraisal of reported cases.

CONCLUSION

In the aftermath of an ocular bee sting, close surveillance for inflammation and infection is essential. Individual manifestations of these injuries vary in timing, type, and severity; therefore, the accessibility of the stinger and the evolving clinical picture should guide therapeutic decisions.

A Case Series of Bee Sting Keratopathy With Different Outcomes in Malaysia

We report three patients with corneal bee sting at our tertiary care center in a three-year period starting from 2014 to 2016. All patients sustained a bee sting injury to the cornea. All patients received early preoperative topical antibiotics, topical cycloplegic and intensive topical steroids. However, the timing of the initial presentation, the duration, and the location of the retained stinger differed in each case leading to different postsurgical outcomes.

Bee sting of the cornea: A running case report

Bee stings that present with ocular sequelae are infrequently reported in the literature. The present report is of a retained corneal bee stinger with a delayed presentation. A review of case reports reveals a number of potential ocular complications of bee stings. The ocular sequelae and treatment options are reviewed.

"It stings a bit but it cleans well": venoms of Hymenoptera and their antimicrobial potential

Venoms from Hymenoptera display a wide range of functions and biological roles. These notably include manipulation of the host, capture of prey and defense against competitors and predators thanks to endocrine and immune systems disruptors, neurotoxic, cytolytic and pain-inducing venom components. Recent works indicate that many hymenopteran species, whatever their life style, have also evolved a venom with properties which enable it to regulate microbial infections, both in stinging and stung animals. In contrast to biting insects and their salivary glands, stinging Hymenoptera seem to constitute an under-exploited ecological niche for agents of vector-borne disease. Few parasitic or mutualistic microorganisms have been reported to be hosted by venom-producing organs or to be transmitted to stung animals. This may result from the presence of potent antimicrobial molecules in venoms, histological features of venom apparatuses and selective effects of venoms on immune defenses of targeted organisms. The present paper reviews for the first time the venom antimicrobial potential of solitary and social Hymenoptera in molecular, ecological, and evolutionary perspectives.

Successful treatment of corneal wasp sting-induced panuveitis with vitrectomy

Background

This study aims to present the management and clinical findings of a case of corneal wasp sting and to report the outcome of corneal change and panuveitis after vitrectomy.

Findings

Clinical findings, anterior segment photographs, corneal endothelial changes, and medical treatment of corneal wasp sting-induced panuveitis are presented. A 95-year-man was stung by a wasp on his left cornea. A severe conjunctival hyperemia, marked corneal edema, corneal epithelial defect, and uveitis developed. As soon as the patient visited our clinic, topical corticosteroid and antibiotics were given, but corneal endothelial damage and uveitis did not improve. Anterior chamber irrigation was performed with oxiglutatione solution to rinse out the wasp venom. Corneal edema and anterior uveitis improved but the endothelial cell density gradually decreased and the vitreous opacity deteriorated. Therefore, a 23-gauge vitrectomy was performed. Subsequently, the corneal edema and panuveitis improved.

Conclusions

Vitrectomy may be an effective treatment for corneal endothelial damage and endophthalmitis induced by a corneal wasp sting.

Corneal honey bee sting: endoilluminator-assisted removal of retained stinger

To report the clinical findings and a novel method of removal of bee sting using an endoillumination light source the following methods were used: clinical presentation, slit-lamp photographs, serial endothelial images and surgical management of a case of retained bee sting in the cornea. The bee sting was surgically removed by forceps under focal illumination with an endoillumination light source. Topical steroids and cycloplegics were given postoperatively to control the inflammation. The patient had complete visual recovery and partial resolution of endothelial changes after 1 year of treatment. The clinical picture of a corneal honey bee sting resembles keratouveitis. Focal corneal infiltrate and associated low-grade uveitis tend to persist if treated with topical steroids only. Early recognition and prompt removal of the stinger may help in the early resolution of anterior segment inflammation and prevent irreversible damage to endothelial cells.

Management of corneal bee sting

Corneal bee sting is an uncommon environmental eye injury that can result in various ocular complications with an etiology of penetrating, immunologic, and toxic effects of the stinger and its injected venom. In this study we present our experience in the management of a middle-aged male with a right-sided deep corneal bee sting. On arrival, the patient was complaining of severe pain, blurry vision with acuity of 160/200, and tearing, which he had experienced soon after the injury. Firstly, we administered conventional drugs for eye injuries, including topical antibiotic, corticosteroid, and cycloplegic agents. After 2 days, corneal stromal infiltration and edema developed around the site of the sting, and visual acuity decreased to 100/200. These conditions led us to remove the stinger surgically. Within 25 days of follow-up, the corneal infiltration decreased gradually, and visual acuity improved to 180/200. We suggest a two-stage management approach for cases of corneal sting. For the first stage, if the stinger is readily accessible or primary dramatic reactions, including infiltration, especially on the visual axis, exist, manual or surgical removal would be indicated. Otherwise, we recommend conventional treatments for eye injuries. Given this situation, patients should be closely monitored for detection of any worsening. If the condition does not resolve or even deteriorates, for the second stage, surgical removal of the stinger under local or generalized anesthesia is indicated.

Corneal bee sting misdiagnosed as viral keratitis

PURPOSE

To report a case of chronic keratouveitis caused by a missed bee sting injury.

METHODS

A 17-year-old boy was referred for management of unresponsive viral keratouveitis. Ocular examination revealed corneal edema and scarring, atrophic patches on the iris, and anterior polar cataracts. Surprisingly, examination also revealed a retained intracorneal bee stinger. A retrospective inquiry confirmed a bee sting injury 2 years ago.

RESULTS

The patient was started on medical treatment and underwent operative removal of the bee stinger. Postsurgery, visual acuity improved, and the corneal edema regressed over a 1-month follow-up.

CONCLUSIONS

In cases of chronic keratouveitis, a meticulous examination is mandatory to rule out unusual causes like a retained corneal bee stinger. A retained intracorneal bee stinger may result in long-term corneal inflammation, which may not be controlled adequately with topical steroids. It should be removed, irrespective of the duration since the injury.

Corneal Bee Sting-Induced Endothelial Changes

PURPOSE

To report the acute management and clinical findings of a case of corneal bee sting and to report the outcome of corneal endothelial cell analysis 1 year after trauma.

METHODS

Clinical findings, anterior segment photographs, corneal endothelial images, and medical treatment of a case of right corneal bee sting are presented. Right and left central corneal endothelial cell analysis was performed by noncontact specular microscopy.

RESULTS

The stinger was removed from the cornea. Systemic, subconjunctival, and topical steroids and systemic and topical antibiotics were given. One year later, a corneal scar and anterior capsular opacity of the lens in the right eye were shown by slit-lamp examination. Endothelial cell analysis determined that the endothelial cell density of the right eye was substantially decreased compared with the left eye.

CONCLUSION

Corneal infiltration gradually decreased, presumably because of the systemic, topical, and subconjunctival steroids. Late complications observed in this case included a substantial decrease in cornea endothelial cell density, a corneal scar, and anterior capsular opacity.

Polymerase Chain Reaction Identification of a Hymenopteran Insect in the Cornea: a Case Report

The type of corneal injuries associated with insect encounters is related to the composition of the foreign body. However, previous reports on corneal foreign bodies as insects were rarely based on scientific evidence. Here, we report on a 49-year-old male who was stung in his left eye by an unknown insect. Emergent keratotomy was performed to remove the embedded corneal foreign body. The removed foreign body was observed under light microscopy, and a fragment of insect was suspected. The sample was sent for molecular analysis. The polymerase chain reaction product was sequenced, subjected to a BLAST search, and identified as an ichneumonoid member of the insect order Hymenoptera.

Corneal honeybee sting

BACKGROUND

We report the complications and management of a retained bee sting injury to the cornea. The case highlights the acute and chronic management of an uncommon injury and its pathogenesis.

METHODS

A 67-year-old man was attacked by a swarm of bees and was referred for severe chemosis on the right eye. A retained corneal bee stinger (ovipositor) was seen but removal was only partially successful. He subsequently developed a large corneal epithelial defect, anterior uveitis, intractable glaucoma, traumatic cataract, toxic optic neuropathy, and corneal scarring. We reviewed the literature on corneal bee sting injuries and their complications.

RESULTS

Inflammation was controlled with topical steroids and the patient underwent a combined phacoemulsification and trabeculectomy with mitomycin-C for uncontrolled glaucoma. However, optic neuropathy did not resolve.

INTERPRETATION

Corneal bee sting injuries are uncommon but can result in severe sight-threatening complications such as toxic optic neuropathy. Early recognition of the possible complications and appropriate treatment may help to prevent permanent loss of vision. Removal of a retained corneal bee stinger remains controversial.

Ocular lesions arising after stings by hymenopteran insects

PURPOSE

To describe the ocular lesions that occur after stings from hymenopteran insects.

METHODS

We examined the ocular alterations in five patients who suffered ocular trauma from hymenopteran insect stings.

RESULTS

In 4 cases where the insect was identified as a wasp, all the patients presented with persistent corneal decompensation and two presented with total cataract, requiring surgical treatment. In the case of trauma by a bee sting, the patient presented with corneal edema and an inflammatory reaction of the anterior chamber with total regression of these alterations after clinical treatment.

CONCLUSION

Although a rare occurrence, ocular trauma caused by hymenopteran insects can result in severe ocular alterations in humans.

Corneal bee sting with retained stinger

Bee stings of the cornea are rarely reported, but have the potential for causing serious ophthalmologic injuries. We present a case of corneal bee sting with retained stinger apparatus and associated iritis and discuss the pathologic mechanisms of injury, evaluation, and treatment of these uncommon presentations.