Tick manifestation of the upper eyelid

Case Report A 4 year old boy was brought by his mother, with complaints of an itchy eyelid and pain in the right superior eyelid. His mother informed that they had returned from a vacation in Konkan region of Western Maharashtra, 3 days ago. His complaints began on their return home. Slit-lamp examination revealed a single large 5–6 mm black swelling with stuck on appearance on the temporal aspect of the right upper lid. It was initially diagnosed as a ruptured stye. He was prescribed an oral anti-inflammatory syrup along with moxifloxacin ointment for local application and was asked to review if his symptoms continued to persist [Figure 1]. The following morning his mother noticed that the black swelling had fallen off on the bed. On retrieval it was noted to be a moving ectoparasite. [Video 1]. She preserved it and brought it to the clinic for inspection. After it fell off, the patient was relieved of his symptoms and was asked to continue local ointment moxifloxacin application twice a day for 3 days. On further questioning, it was revealed that the boy had played with dogs when on vacation. Thus, a dog tick infestation of the eyelid was identified.Figure 1: Tick attached to superior eyelid {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_9hr9m3n0"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Discussion Ticks are hematophagous arthropods causing infestation of ocular tissues, leading to severe systemic and local complications. Tick infestation of ocular tissue is a rare occurrence. Both soft ticks and hard ticks can infest ocular tissue. Compared to the soft ticks, Ixodidae differ in their life cycle as they attach to a host painlessly and are generally unnoticed. They remain in place until they engorge and are ready to change their skin for a further stage of development. This characteristic feature may explain why they could infest a young boy and remain unnoticed for a longer duration.[1] A similar case was reported by Hakami et al. in a young girl in which the ectoparasite fell off from the eyelid after laying eggs.[2] Many methods of tick removal have been described such as application of a hot match to the tick body, covering the tick with petroleum jelly, gasoline, alcohol, or nail polish. Application of lidocaine to tick body and passing a suture needle through the tick are risky as they may trigger injection of salivary fluids and possible transmission of disease-causing microbe.[3] Kondo et al. suggested rolling removal technique for a tick embedded in the eyelid. Manual removal, with the forceps held perpendicular to the skin, can be difficult to control as the skin around the eye is extensible. Rotating the tick around its body requires minimal force as the tick hypostome has multiple backward-facing denticles.[4] Love et al. reported the use of a blepharoplasty incision, including en bloc excision. Being an invasive method, it bears the risk of loss of ocular tissue and disruption of the ocular architecture, especially for a child, as in the current case.[5] In conclusion, safe mechanical removal of ticks with forceps is recommended. Our case depicts a rare presentation, wherein the tick has spontaneously fallen off the patient's eyelid. Ophthalmologists are rarely confronted with ectoparasites and should be aware of the importance of timely, safe, and complete removal of ticks and the possible threat of tick-borne diseases. Importance of protective clothing and goggles must be emphasized. Patients may need to undergo blood and serologic tests for tick-borne diseases and be monitored with frequent follow-up visits. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.