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Observation
February 2015

Presumed Bee Stinger Retained Intraocularly in the Absence of Inflammation

Author Affiliations
  • 1Instituto de Olhos de Manaus, Manaus, Brazil
  • 2Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
  • 3Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
JAMA Ophthalmol. 2015;133(2):222-223. doi:10.1001/jamaophthalmol.2014.4353

There are multiple reports in the literature describing ocular trauma due to bee and wasp stings, and most of the complications are caused by either venom or the local inflammatory reaction,1 potentially leading to corneal edema, uveitis, cataract,1,2 and, less frequently, optic neuritis.3 Although there are controversies in the management of retained bee stingers, surgical removal is usually indicated.4 We report an unusual case of a presumed intraocular bee stinger embedded in the lens for 5 years with surrounding cataract but no signs of intraocular inflammation.

Report of a Case

A man in his late 50s presented to the local eye clinic after being invited to an ophthalmological examination for a population-based survey on prevalence of blindness. He was satisfied with his visual acuity and reported a slight decrease in the upper visual field of his left eye. His best-corrected distance visual acuity was 20/20 OD and 20/32 OS; intraocular pressure was 10 mm Hg OD and 12 mm Hg OS. On slitlamp examination, the right eye showed only a small pinguecula. His left eye also showed a pinguecula, no signs of conjunctival hyperemia, a mild paracentral corneal opacification, and an intraocular foreign body embedded in the lens and touching the upper temporal pupil border (Figure 1A). There were no signs of anterior chamber inflammatory reaction. After instillation of tropicamide, 1%, and phenylephrine hydrochloride, 10%, we observed that the surrounding lens was opaque (Figure 1B).

Figure 1.  Clinical Photographs Showing Presumed Bee Stinger
Clinical Photographs Showing Presumed Bee Stinger

A, Presumed bee stinger (arrowhead). B, Bee stinger with associated lens opacification (arrowhead), after instillation of mydriatic agents. Images were captured with an iPhone 5 (Apple Inc) in front of the slitlamp optics.

Once we noticed the intraocular foreign body, we asked him whether he had a history of ocular trauma. He reported that 5 years earlier, he had gotten multiple bee stings while riding a horse in the local rural area. At that time, he had severe pain and traveled to the next nearest eye clinic. The local ophthalmologist removed multiple stingers from both eyes and prescribed topical drugs; the patient felt better a few days later and never returned for an ocular evaluation.

Optical coherence tomographic images (iVue 100; Optovue) of the anterior chamber demonstrated stromal opacification of the cornea presumably at the stinger inoculation site (Figure 2A). The presumed stinger reached 1.04 mm into the anterior chamber (Figure 2B), while its intralenticular part could not be adequately measured.

Figure 2.  Optical Coherence Tomographic Images Showing Corneal and Lens Opacification
Optical Coherence Tomographic Images Showing Corneal and Lens Opacification

Optical coherence tomographic images of the corneal opacification (arrowhead) (A) and the presumed bee stinger associated with lens opacification (arrowhead) (B).

Discussion

This presumed stinger is most likely from Apis mellifera (Vera Lucia Imperatriz-Fonseca, PhD, written communication, November 20, 2013); surgical removal of the stinger and further analysis could confirm this hypothesis. Apis bees, Pogonomyrmex ants, and multiple wasps have a barbed sting lancet and are able to perform sting autotomy, the self-amputation of the stinger and poison sac (which remain in their target) as a form of self-defense from vertebrate predators.5

Considering the stinger’s dimensions and the patient’s corneal thickness (594 µm centrally) and anterior chamber depth, it is unclear how the stinger became embedded in the lens. One possible explanation is an indentation of the globe at the moment of trauma, temporarily reducing its axial dimension.

To our knowledge, this is only the second report in the literature of a presumed innocuous intraocular bee stinger attached to the lens1 and the first time that optical coherence tomographic images were used to analyze the presumed stinger. The inactivation of the toxins after the acute phase and the volume of the bee venom could explain the absence of inflammatory reaction.1

Although there is controversy regarding the ideal approach to retained bee and wasp stingers,6 we decided not to remove it because no signs of intraocular inflammation were found. Moreover, the patient was satisfied with his visual acuity and refused to undergo phacoemulsification. We opted to schedule annual eye examination with further cataract surgery when visual acuity decreases to a point that causes dissatisfaction.

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Article Information

Corresponding Author: João M. Furtado, MD, PhD, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Av Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil 14049-900 (furtadojm@gmail.com).

Published Online: November 6, 2014. doi:10.1001/jamaophthalmol.2014.4353.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by Sight First Grant 1758 from the Lions Club International Foundation and by Fundação de Amparo à Pesquisa do Estado de São Paulo. Dr Furtado was supported by the Programa Ciência sem Fronteiras postdoctoral scholarship from Conselho Nacional de Pesquisa e Desenvolvimento Tecnológico.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Solange R. Salomão, PhD, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil, and Vera Lucia Imperatriz-Fonseca, PhD, Universidade de São Paulo, São Paulo, Brazil, helped with the description of the stinger; they received no compensation.

References
1.
Gilboa  M, Gdal-On  M, Zonis  S.  Bee and wasp stings of the eye: retained intralenticular wasp sting: a case report.  Br J Ophthalmol. 1977;61(10):662-664.PubMedGoogle ScholarCrossref
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Arcieri  ES, França  ET, de Oliveria  HB, De Abreu Ferreira  L, Ferreira  MA, Rocha  FJ.  Ocular lesions arising after stings by hymenopteran insects.  Cornea. 2002;21(3):328-330.PubMedGoogle ScholarCrossref
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Maltzman  JS, Lee  AG, Miller  NR.  Optic neuropathy occurring after bee and wasp sting.  Ophthalmology. 2000;107(1):193-195.PubMedGoogle ScholarCrossref
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Chauhan  D.  Corneal honey bee sting: endoilluminator-assisted removal of retained stinger.  Int Ophthalmol. 2012;32(3):285-288.PubMedGoogle ScholarCrossref
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Shorter  JR, Rueppell  O.  A review on self-destructive defense behaviors in social insects.  Insectes Soc. 2012;59(1):1-10. doi:10.1007/s00040-011-0210-x.Google ScholarCrossref
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Roomizadeh  P, Razmjoo  H, Abtahi  MA, Abtahi  SH.  Management of corneal bee sting: is surgical removal of a retained stinger always indicated?  Int Ophthalmol. 2013;33(1):1-2.PubMedGoogle ScholarCrossref
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