DSEK for corneal decompensation post bee sting injury.

Sir,

Bee sting injury to the cornea is an infrequent occurrence and is known to cause significant visual morbidity. Due to the rarity of bee sting corneal injuries, there is no proper consensus or guidelines regarding the management protocols.[1]

Herein, we report a case of corneal decompensation with corneal infiltrate in retained intracorneal bee sting posttrauma managed by removal of sting in the acute phase and later visual rehabilitation done by descemet stripping endothelial keratoplasty (DSEK).

A 65-year-old pseudophakic male who had sustained bee sting injury to the right eye came to our cornea clinic approximately 1 week after the trauma with defective vision counting finger close to face(CFCF) and pain. His records from other hospital showed that he was treated with systemic hydrocortisone and topical steroids; an attempt of removal of the sting was mentioned. On slit-lamp examination, a dense, focal, 2 mm × 2 mm anterior-to-mid stromal infiltrate was noticed between 10’o clock and 11’o clock positions with diffuse dense striate keratopathy with corneal edema [Figure 1a]. No obvious bee sting was visible, and even with aid of anterior optical coherence tomography due to intense edema initial pictures were inconclusive, however, after 2 weeks of conservative treatment with oral steroids, topical steroids, and sodium chloride 5%, there was a slight improvement in corneal edema, and the bee sting was faintly visible. It was noted to be embedded in deep corneal stroma penetrating the anterior chamber necessitating surgical removal. With the help of the endo illuminator, the stinger was carefully removed in toto along with the venom sac from the endothelial side [Figure 2].

Figure 1

Slit-lamp photograph of the patient at initial presentation with corneal infiltrate and dense striate keratopathy (a) and post descemet stripping endothelial keratoplasty at 1 month (b)

Figure 2

Slit-lamp photograph showing a zoomed image of the bee sting embedded in the cornea (a) and photograph of the bee sting after removal (b)

Despite the removal of bee sting and medical management, there was no improvement in bullous keratopathy during the follow-up period. In view of only endothelial dysfunction with clearer stroma and epithelium, he underwent DSEK approximately 5 months post bee sting injury. The surgery was uneventful; however, challenges with flabby iris and relatively larger pupil size were noted. Postoperative course was good, with best-corrected visual acuity of 6/18 at 1 month [Figure 1b].

Gürlü et al. and Chuah et al. studies have reported a decrease of the corneal endothelial cell density post corneal bee sting injuries over a period of time.[23] DSEK is a viable treatment option in cases of corneal decompensation and bullous keratopathy secondary to bee sting injury; however, the associated inflammation and involvement of other anterior segment structures can be limiting factors during surgery. Gudiseva et al. in their case series of 11 cases of bee sting injury have reported five cases of corneal decompensation which was managed by penetrating keratoplasty combined with cataract/trabeculectomy.[1] There have been isolated case reports in the literature on the management of corneal decompensation with DSEK.[4] We planned DSEK 5 months post the bee sting injury once the inflammation subsided, and the eye became quiet. We did encounter challenges in air tamponade due to flabby iris and 5 mm pupil. Eventually, our patient regained good postoperative vision; however, sequelae of bee sting injury in the form of atrophic iris and sluggishly reacting pupil were noticed.

The consequences of a corneal bee sting can be devastating. The need for keen observation to look for bee sting cannot be overemphasized, and the use of anterior segment imaging when available can aid in early diagnosis. In cases of no improvement of clinical course, wound exploration should be considered to identify deep or hidden complete or remnants of bee sting. Since the primary pathophysiology is endothelial dysfunction, lamellar procedures in the form of endothelial keratoplasty are a better option for visual recovery. However, all these cases require close observation and long-term follow-up.

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Conflicts of interest

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