Insect sting ocular damages have been reported to be associated with various insects and spiders such as bee, wasp, caterpillar, insect wings, fly larva and fire ants. Ocular bee stings are rarely reported but have the potential to cause severe sight-threatening complications. Here is a case report of an elderly female with history of multiple head, facial and ocular bee sting injuries while working in her fields. She had multiple bee sting marks over both sides of the face with some retained stingers over face. Lids were edematous with presence of 2 retained stinger on left side. A round to oval corneal ulcer of size 2.5 x 2 mm was present in temporal quadrant with linear abrasions and presence of mild corneal edema and descemet’s folds. On right side, a circular nebular corneal opacity was present in inferior quadrant. Management included removal of retained stinger using forceps under local anaesthesia, pad and patch of epithelial defect with antibiotic drops and ointment. Further course included frequent topical antibiotics with lubricant eye drops, following which corneal ulcer healed in a course of 3 weeks.
Ocular bee stings are rarely reported but have the potential to cause severe sight-threatening complications [1,2]. Some of the complications reported in the literature include: catarrhal conjunctivitis, corneal epithelial defect, corneal edema, decreased corneal endothelial cell density, corneal scarring, secondary bacterial keratitis, iris heterochromia, internal ophthalmoplegia, cataract, lens dislocation, anterior uveitis, hyphema, glaucoma, toxic optic neuropathy and chorioretinopathy [3-7]. Insect sting ocular damages have been reported to be associated with various insects and spiders such as bee, wasp, caterpillar, insect wings, fly larva and fire ants . The considerable compositional differences in poison gland secretions among different bee species are thought to be a contributory factor to the wide range in the degree of response [9,10]. The substantial variation in clinical presentation and outcomes from case to case has made it difficult to establish a therapeutic algorithm for corneal bee stings. Among 50 articles on the topic since the earliest case report in 1955 .
A 67 years old female was referred to us from otorhinolaryngology department with history of multiple head, facial and ocular bee sting injuries while working in her fields 1 day back. She had multiple bee sting marks over both sides of the face with some retained stingers over face which were removed in the emergency department. On ocular examination, visual acuity OD was 6/18 improving to 6/9 and 6/18 OS not improving with pin hole. Lids were edematous bilaterally more
towards left side. Retained stinger (2 in number) were present on left eyelid;1 in upper lid and 1 on lower lid. Mild conjunctival erythema and chemosis were present on left side. On left side, a round to oval corneal ulcer of size 2.5 x 2 mm was present in temporal quadrant with linear abrasions surrounding it taking fluroscein uptake. there was presence of mild corneal edema along with descemet’s folds. On right side, a single circular nebular corneal opacity of size 1.2x1 mm was present in inferior quadrant. Management included removal of retained stinger using forceps under local anaesthesia, pad and patch of epithelial defect in left eye with antibiotic drops and ointment for 24 hours with daily review for slit lamp examination. Further course included frequent topical antibiotics with lubricant eye drops, following which corneal ulcer healed in a course of 3 weeks and visual acuity returned to 6/9(p) (Figure 1-5).
Ocular bee stings may present in a penetrating, immunologic,
or toxic form or as a combination of all 3 forms. Although
the response to a corneal or conjunctival bee sting is usually
local, a generalized reaction such as anaphylaxis may occur
in some patients who have experienced previous bee injury.
Complications associated with ocular bee stings may involve
the cornea, conjunctiva, anterior chamber, lens, optic nerve,
or extraocular muscles [1,2,12-14]. It is thought that pain,
hyperalgesia, and inflammation reactions associated with
bee stings are most likely the result of injected bee venom,
rather than the stinger itself . The whole bee venom was
composed of polypeptides, enzymes, amines, and so on. Major
active peptidergic components of bee venom that resulted in
inflammation and pain were apamin, mast cell degranulating
peptide, phospholipase A2–related peptide, and melittin .
Chen et al.  presented that mast cell degranulating
peptide and phospholipase A2–related peptide and melittin
caused more pain-related reactions, whereas only apamin and
melittin produced thermal and mechanical hypersensitivity.
Apamin, which comprises about 2% of bee venom, is a
neurotoxin that blocks neurotransmission via a potassium ion
channel blockade [1,12,17,18]. In particular, melittin comprised
over 50% of whole bee venom was the most potent peptide to
cause inflammation and hypersensitivity .
Honey bee venom has a toxic effect on the corneal endothelial
cells . The acetylcholine in the bee venom can cause corneal
edema and corneal edema after bee sting usually ends with
bullous keratopathy .
Although there was no retained stinger at the time of
presentation intracorneally, but retained stinger were present
in both upper and lower lids which caused a large corneal ulcer,
corneal edema and descemet’s striae. It was only after removal
of those stinger with forceps which lead to early healing of the
corneal ulcer. Further faster recovery was aided by intensive
follow up, topical antibiotics and artificial tears.
In conclusion, ocular surface bee stings may cause
penetrating, immunologic, and toxic injuries. Though corneal
bee sting injuries are rare occurrences, they are often associated
with potential severe visual impairment. An immediate and
prompt surgical intervention to remove the bee stinger and
concurrent intensive antibiotic therapy can curtail the toxic
effects of a bee sting and hence improve visual outcomes.