 All right, we're going to stop looking for the future and take a little walk into the past here. No finance for the closures. Our story begins about 100 million years ago in the Cretaceous period when the first species that diverged from wasp and became what is the modern day honey bee became into existence. This was a transitional species that I just mentioned. And it was instrumental in the evolution of radiation of Andrew sperms or the spread and diversification of flora. However, in 1950s, Warwick Kerr in Brazil was interviewing the European and the African species of bees with the hopes that he'd be fined a more productive and more tropically acclimated species. Little did he know these bees started to become more and more defensive. And in 1957, a replacement, a substitute beekeeper, released 26 colonies into the wild. These became what are known colloquially as the killer bees. These bees are known to swarm more frequently. They have greater defensiveness. They guard more aggressively. They're known to chase prey or attackers up to 400 meters, some say 500 meters, from their beehive. And they've killed upwards of 1,000 people already. They're also the reason we have some pretty mediocre horror films already in existence. After 1957, they spread from Brazil, both south and north, into the United States. Some project that the northern level would be about, the northern border of Arizona. However, with climate change, they could go further north. And their progenitors have already been discovered in New York, where some say the Wu-Tang Clan and the killer bees are direct descendants. That's still speculation. I wouldn't write that in a paper. So this brings us to our unlucky patient, who is a 49-year-old gentleman, no significant past medical history, no significant past arcler history, who was stung in the right eye by a rogue bee the day prior to presentation. On exam, he had a vision of 1,200, and that affected eye. He had equal pupils. His pressures were normal. And his anterior exam showed this. Here you see a stinger with a local infiltrate, as well as pretty significant decimal membrane folds. Looking into the eye, he had 3 plus cell in the AC. He had a follicular reaction on his pupil congenitiva, but a normal posterior assignment exam. There was a hazy view in. So what about bee venom? He has a bee stinger stuck in his cornea. Well, bee venom contains polypeptides, enzymes, and amines, although the most important is melitin, which comprises about half of bee venom. It's the most potent component of all of these other proteins and enzymes that get injected with the bee venom into the victim. And melitin can cause a potentiation of secretory polyphospholite-base A2, which causes no susceptive problems, as well as destruction of red blood cells. It's also been studied how the venom is delivered. And it is delivered on a time-based dose response curve with the proper amount of bee venom being about 100 to 200 milligrams to induce the most significant pain response in the victim. This is all very important information. Also, I don't know if you knew, but a bee stinger is a barbed, modified OV-positor, meaning in what in other instance, the female would use to deposit A's. This is why male bees can't sting you. Barbed being very important. All right, so this guy's not the only unlucky guy who's been stung in the I by a bee. This actually has been reporting the literature not a lot, but maybe about as much as, I don't know, amen or something, 60. You see cornea stings. You can see conjunctival sequelae, anterior uveitis, optic neuritis is popular, papillodema, neuritis. These things have all been described in the literature. In cornea, they did a case series of four bee stings. They were either in the cornea or the conjunctiva. All four of these cases were removed immediately. The bee stings were removed immediately. One of them, interestingly, was directly in the interface of a Lasik flap, the unfortunate man. But they're all treated topically with steroids, antibiotics, and a cyclopegic, and all had good visual outcomes. However, it's been noted and studied using microscopy that corneal bee stings create a reduction in endothelial cell counts, actually quite significantly. So in this 2006 case report, over one year, you can see that the cell density went from 2,900 in the left eye to non-affected eye to 1,300 in the effective eye. In 2011, the reputable journal, the Journal of the Cataract Intractive Surgery, reported the first known desec after a bee sting to the cornea. This patient was also treated with removal, antibiotics, topical steroids, but his cornea decomposited to the point that he required cataract surgery and a desec. There was speculation that poor compliance might have contributed to his problem. Here's a picture. You can see that not only the stinger, but the vesicle, or the venom sac, is stuck in the cornea with a local infiltrate. Another case showed in the clinical ophthalmology that a bee stinger impelled in the cornea and unable to be removed from the slint lap required surgical intervention where they actually had to do a keratectomy to remove it and suture the cornea. This paper then did a quick review of the literature and started discussing what should be the management options when somebody is unfortunate enough to be stung in the cornea with a bee. There's no really great clinical trial that has elucidated what the best management is. However, there have been reports that optic neuropathy or optic neuritis can result from a periocular or an ocular bee sting. Most of these patients are treated with medical prednisone, but some have been treated with retrobalobar or periobar or oral steroids. A 1991 article in the journal Clinical Neurothymology showed that with an ocular bee sting, there was actually evidence of demyelination that occurred with a delayed VEP even after the resolution of the optic neuritis, the optic nerve swelling. And this brings us to the point of what should we do. Well, based on the review I did of literature, you should remove the stinger if possible. I don't know if I could advocate a surgical intervention unless there is corneal decolumization, ongoing inflammation, because there are other case series that show that a retained stinger can be left as an inert substance, because most of the venom is injected and delivered into the cornea in the first so many minutes after the injection. Other people recommend that you remove it any means possible, probably short of a nucleation. But you must remove it if it's into the interior chamber, meaning it's done a full penetration, or if there's ongoing inflammation in the cornea, or they enter your chamber, even with treatment. The other question is, what kind of steroids do we use? Topical steroids is what's most commonly been used for these corneal bee stings. However, there are a few case reports, and one that did a case series where they looked at the use of oral steroids or systemic steroids. And that, which was not a prospective randomized trial, they did show that their outcomes were good with oral steroids. But the other question is, could that prevent the other central nervous system phenomenon from occurring? Optic neuropathies or optic neuritis? We don't know. It's a study out there to be done by you. So for now, topical antibiotics, topical steroids, and cyclopelagic is the best course of action. So back to our patient who did have a little bit of the stinger left in the cornea, not able to be removed, but they decided not to take him to a surgery. He was 20, 20 at two weeks. He quieted on topical medications, and even though he had persistent forward body sensation, did quite well even leaving the stinger in place. That is my talk, my abstract. Are there any questions about corneal bee stings? Good.