conjunctival tick attachment is a rare occurrence , with only 7 cases reported in the literature .
the tick species ixodes holocyclus is found in australia and belongs to the family of hard ticks , ixodidae , which are a group of blood - sucking acarine ectoparasites [ 1 , 2 ] .
it is also known as the paralysis tick because it produces a toxin that can cause motor paralysis , which is mainly a problem seen in veterinary medicine and rarely in humans , although children under 5 years of age are at greatest risk .
ticks are known vectors of infectious diseases and are associated with a range of ocular and systemic conditions .
we describe a rarely seen ophthalmic finding : conjunctival attachment of a live paralysis tick .
we also discuss the literature regarding ocular tick attachment , clinical features , and management .
a 10-year - old boy presented to the clinic with a 2-day history of right - eye redness and itch .
the patient was visiting a property surrounded by bush land in the northern suburbs of sydney , n.s.w .
his visual acuity was 6/6 in the right eye and 6/5 in the left eye . slit lamp examination revealed a live translucent - bodied organism with pulsatile fluid movement ( at a different rate to the patient 's heart ) , firmly attached to his right temporal bulbar conjunctiva ( fig .
there was conjunctival vessel dilatation surrounding the organism , but otherwise , ocular examination was unremarkable . under general anaesthesia , the conjunctival tissue and the organism onto which it was attached ( see arrow in fig .
1b ) were elevated and excised en bloc . the excised area ( approximately 3 mm in diameter )
the patient was started on a 1-week course of chloramphenicol ophthalmic ointment and oral cephalexin 4 times a day .
the recovery of our patient , after 3 weeks , has so far been uneventful .
the organism was examined and identified as the larval stage of the tick species i. holocyclus from the family of hard ticks , ixodidae .
histopathological examination revealed deep embedding of the larval tick 's mouthparts , with extension into the conjunctival stroma ( fig .
conjunctival attachment of a live tick is a rare occurrence with only 7 cases ( 6 reports ) found in the literature [ 4 , 5 , 6 , 7 , 8 , 9 ] .
the paralysis tick , i. holocyclus , is one of 7 species in the subgenus sternalixodes , all of which are exclusive to australia .
the paralysis tick is distributed predominantly along the east coast from north queensland to southern victoria , and possibly into tasmania ( fig .
hard ticks , which include the paralysis tick , go through 4 life stages from the egg to larva , to nymph , and finally to the adult stage . from the vegetation where they 
quest for a host , female ticks attach onto passing vertebrate hosts , including humans , and feed on the blood .
paralysis ticks , including the larval form , have long mouthparts to enable a strong attachment to the host [ 1 , 10 ] .
the paralysis tick tends to show seasonality in life stages , and the larval stage is most active at this time of the year ( summer ) in australia . during blood feeding , ticks transfer saliva , which contains a cocktail of chemicals including toxins , various allergy - inducing proteins , and potentially disease - causing pathogens [ 10 , 11 , 12 , 13 ] .
tick bites to the eye may cause ocular irritation at the attachment site , conjunctivitis , uveitis , keratitis , and vasculitis .
ticks can become embedded in the meibomian gland orifice and cause eyelid swelling and pain .
although rarely reported in humans , toxins transmitted from the paralysis tick 's saliva have been associated with ascending motor paralysis , diplopia , blurred vision , and photophobia especially in children .
the paralysis tick , however , needs several days of engorgement on its host before these signs of tick paralysis are manifested .
this is because adult ticks go through various phases of feeding , including a slow phase , where the production of toxins in the tick 's salivary glands is very low on day 1 and 2 of the blood feed , and a rapid phase , where salivary production peaks on day 5 [ 3 , 13 ] .
the timing of these phases varies according to life stage and , typically , larvae feed for a shorter duration .
our patient had a larval tick attached to his conjunctiva for 2 days and has so far not developed any visual or neurological symptoms .
paralysis ticks are vectors of infectious diseases such as queensland tick typhus and flinders island spotted fever .
tick bites have been associated with lyme borreliosis , although more conclusive evidence is required to determine that the borrelia bacteria is present in ticks in australia . regarding the larval stage of hard ticks , the infectious diseases society of america ( idsa ) does not recommend routine antibiotic prophylaxis due to the low risk of disease transmission .
this is because the larval form typically has not previously fed on another host from which they may have acquired a pathogen .
however , antibiotic prophylaxis is often given when the tick bite has occurred in a location where infection would have more detrimental consequences , such as the eye .
our patient was started on a 1-week course of oral cephalexin and chloramphenicol ophthalmic ointment .
tick allergy has been well documented and ranges from mild urticaria , allergic conjunctivitis , to anaphylaxis .
it was recently recognised that patients previously bitten by the paralysis tick may subsequently develop anaphylaxis from the consumption of mammalian meat and meat by - products such as gelatine , although this condition has not yet been associated with the larval stage .
the mechanism of this is beyond the scope of this paper , but clinicians may consider close monitoring of the patient for hypersensitivity reactions .
five out of the 7 cases of conjunctival tick attachment had the removal by conjunctival excision ( table 1 ) .
the reasons for surgical removal were either a firmly attached tick [ 5 , 6 , 7 ] or simply that the conjunctiva was involved .
one case report proposed that blunt , medium - tipped , angled forceps offered the best result for removing ticks not deeply seated in the conjunctiva .
another case successfully used blunt force with a cotton applicator but admitted difficulty with this approach for embedded ticks .
in all 7 cases , recovery of the patient was uneventful , and no parts of the tick remained in the conjunctiva .
the australasian society of clinical immunology and allergy ( ascia ) recommends first killing an embedded tick with ether - containing agents or permethrin - based products and then letting it drop off the host or removing it with fine - tipped forceps to avoid squeezing saliva into the host 's vasculature .
however , ascia recognises that this method is not suitable for all patients , especially when the tick is embedded in sensitive areas of the body such as the eye . despite the different tick removal methods postulated ,
there is consensus in the literature that the goal of treatment should be complete removal of the tick from the host to prevent further transmission of pathogens , allergens , and toxins [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ] . in our patient ,
the larval tick was too firmly attached to the bulbar conjunctiva , so complete and safe removal of it using forceps was not possible in a conscious child .
it is not uncommon for ticks to inject further toxins into the host if disturbed .
the tick was removed completely and our patient has so far not experienced any post - operative complications or systemic illness .
the goal of treatment for conjunctival tick attachment should be to completely and safely remove the tick as soon as possible to prevent further transmission of pathogens , toxins , and allergens to the patient .
surgical removal of the tick and surrounding conjunctiva ( with general anaesthetic if necessary ) proved simple and effective with no adverse sequelae , a decision supported by the histopathological examination revealing deep embedding of the tick 's mouthparts into the conjunctiva .
 we describe a rare clinical finding of conjunctival tick attachment in a child . a 10-year - old boy presented to the clinic with right - eye itch . 
 he was found to have a live tick firmly attached to his right temporal conjunctiva . 
 the tick was identified as the larval stage of the paralysis tick , ixodes holocyclus . 
 the tick was removed completely by conjunctival excision . 
 although various methods of removing a tick have been described in the literature , the goal of treatment is the safe and complete removal of the tick to prevent further transmission of pathogens , allergens , and toxins to the patient . 
Introduction
Case Report
Discussion
Conclusion
Disclosure Statement