Author Affiliations: Departments of Ophthalmology (Drs D. Wiwatwongwana and A. Wiwatwongwana) and Parasitology (Dr Jariyapan), Chiang Mai University, Chiang Mai, Thailand.
Bee stings of the eye are rare, most commonly occurring at the cornea, and can cause sight-threatening complications through different mechanisms. The bee stinger contains toxins that induce a local inflammatory reaction. Furthermore, its sharp nature allows it to penetrate deeply and its sawlike architecture and special anatomic features make it very difficult to remove completely. We report a case of bee sting to the eyelid with late migration of the stinger onto the cornea after an assumed successful removal by the patient. To our knowledge, this is the first report to discuss in detail the structure of the bee stinger, which makes it prone to incomplete removal, and the management of this uncommon condition.
A 55-year-old man had sudden sharp pain and redness of the left eye for 1 week. One month prior, he had a bee sting to the left upper eyelid but had removed the stinger. After removal of the stinger, mild painless upper eyelid swelling persisted. Visual acuity was 6/6 OD and 6/36 OS. Examination of the left eye showed mild swelling of the upper eyelid with conjunctival and perilimbal injection (Figure 1A). A fluorescein-positive pinpoint epithelial defect was noted at the superior cornea with multiple scratches across the entire cornea (Figure 1B). There were trace anterior chamber cells and the lens was clear. The pupil and fundus were normal. On eversion of the upper eyelid, a tiny foreign body embedded in the tarsal plate corresponding to the area of the corneal epithelial defect was detected (Figure 1C). Attempted removal of the foreign body with a 27-gauge needle failed. A jeweler forceps was then used to grasp and pull out the foreign body, which resembled a bee stinger (Figure 1D). The patient was treated with combined topical antibiotics and steroids. At 2 weeks' follow-up, he was asymptomatic and the eyelid swelling and corneal epithelial defect had resolved. The stinger of a honeybee normally comprises 2 lancets wrapped together by a single stylet (Figure 2A). Slight pressure was experimentally applied to a fresh stinger by rubbing the stinger between 2 fingers. This caused breakage of the stylet, releasing the 2 lancets (Figure 2B). In comparison with the normal honeybee stinger, the foreign body from our patient resembled a single lancet (Figure 2C).
Figure 1. Findings in a 55-year-old man with a history of bee sting to the left upper eyelid 1 month prior. A, Left upper eyelid swelling with ptosis and conjunctival injection. B, Fluorescein staining of the cornea revealed a pinpoint epithelial defect (arrow) at the superior aspect with multiple linear scratches over the entire cornea. C, Eversion of the left upper eyelid revealed a tiny brownish foreign body (arrow) embedded in the upper tarsus. D, The foreign body pulled out of the tarsus resembled a chitinous bee stinger.
Figure 2. Microscopic examination of the honey bee stinger. A, A chitinous stylet with a proximal bulb and sawlike tip. B, Two separate lancets are situated within the stylet. This could be seen only after the stylet had been crushed. C, The foreign body from the patient's upper tarsus resembled a single lancet.
Complications from bee venom and toxins have been widely discussed in the literature, ranging from anterior segment inflammation to severe vision loss from toxic optic neuritis.1- 5 Mechanical complications from the bee stinger itself, however, have been less mentioned. Little is known about the effects of the chitinous stinger. Some authors suggest that it is inert and can be left in the eye.6
The honeybee stinger possesses a sawlike architecture; therefore, once buried in the tissue, an attempt to grasp it and pull it out in the reverse direction usually results in retention of part of the stinger. Moreover, external pressure may cause the stylet to crush, resulting in release of the 2 lancets into the tissue. The structure assumed to be the entire stinger that had been previously removed in our patient was truly only a single lancet.
Physicians should be aware of the possibility of incomplete removal of a bee stinger even with a history of assumed successful removal, particularly when inflammation persists chronically. Careful examination of the site of injury and adjacent tissue for retained parts of the stinger is mandatory prior to concluding that the inflammation is due to bee venom and toxins. Gentle removal of the stinger is suggested to avoid chronic inflammation and mechanical injury to ocular tissue from possible late migration.
Correspondence: Dr A. Wiwatwongwana, Department of Ophthalmology, Chiang Mai University, 110 Inthawarorot St, Muang District, Chiang Mai, Thailand 50200 (firstname.lastname@example.org).
Financial Disclosure: None reported.
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