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Tick infestation of the upper eyelid

      A 35-year-old day-tripper presented to our emergency department last July with what she thought was a tick nestling in the eyelashes of her upper left eyelid after a visit to the Lake District, United Kingdom (Fig. 1). There was no associated local eyelid reaction.
      Figure thumbnail gr1
      Fig. 1Tick infestation of the left upper eyelash margin.
      Visual acuity was 6/6 in both eyes. Ocular examination confirmed the presence of a live tick-like organism resting on the upper eyelash margin and firmly attached to the adjacent eyelid skin.
      Attempted removal of the live tick using Moorfields forceps at the slit lamp unfortunately resulted in the disembodiment of the parasite and the retention of residual, presumed mouth parts, which remained embedded in the skin. The retained tick parts were excised en bloc under local anaesthetic by lifting up the affected skin with forceps and excising the tissue and healthy margins with Westcott scissors. Hemostasis was achieved with cautery, allowing the wound to heal by secondary intention (Fig. 2). The periocular area was then cleansed liberally.
      Figure thumbnail gr2
      Fig. 2Appearance after en bloc excision.
      The patient was discharged to her general practitioner with a prophylactic course of oral doxycycline (200 mg stat and 100 mg OD for 7 days). Subsequent Borrelia serology was negative, and to date the patient has developed no clinical manifestations of Lyme disease. The residual animal parts were sent to an entomologist (Fig. 3), who was able to identify that the organism was most likely Ixodes ricinus, the sheep tick. We postulate that the tick may have attached itself to the patient’s pullover and latched on to the eyelid as the garment was removed.
      The most economically important ticks belong to the Ixodidae Latr. (Arachnida: Acari), the so-called hard ticks.
      • Keirans J.E.
      • Litwak T.R.
      Pictorial key to the adults of hard ticks, family Ixodidae (Ixodida: Ixodoidea), East of the Mississippi River.
      • Cooley R.A.
      • Kohls G.M.
      The Argasidae of North America, Central America and Cuba, Monograph 1.

      The Connecticut Agricultural Experiment Station. Ticks of the Northeastern United States. Retrieved from www.ct.gov/caes/lib/caes/documents/publications/fact_sheets/TicksoftheNortheasternUnitedStates.pdf. Accessed November 29, 2014.

      Centers for Disease Control and Prevention. Geographic distribution of ticks. Retrieved from www.cdc.gov/ticks/geographic_distribution.html. Accessed November 29, 2014.

      Government of British Columbia. Ticks and Humans. Retrieved from www.agf.gov.bc.ca/cropprot/ticksbc.htm. Accessed November 29, 2014.

      Many species occur in North America, but only a few are significant to human health. These include:
      • Wood tick (Rocky Mountain tick), Dermacentor andersoni (Stiles): Rocky Mountain spotted fever and tularemia are transmitted to humans by adult ticks of this species.
      • Winter tick, Dermacentor albipictus (Packard): This host tick is common on moose, elk, and deer. Consequently, hunters will come across it together with Ixodes scapularis; however, it rarely feeds on humans.
      • American dog tick (wood tick), Dermacentor variabilis (Say): A commonly identified species that transmits the rickettsia responsible for Rocky Mountain spotted fever and tularemia. It does not transmit the spirochete responsible for Lyme disease.
      • Western blacklegged tick, Ixodes pacificus (Cooley and Kohls): Both adults and nymphs are primary vectors of Lyme disease and also human granulocytic anaplasmosis.
      • Blacklegged tick (deer tick), Ixodes scapularis (Say): This is another important vector of human granulocytic anaplasmosis. It also transmits babesiosis and Lyme disease.
      • Brown dog tick, Rhipicephalus sanguineus (Latreille): This cosmopolitan tick is another species that transmits Rickettsia rickettsii (Wolbach) mainly in dogs and occasionally bites humans.
      Although tick infestations of the eyelid are a rare occurrence, there are several published cases in the literature.
      • Samaha A.
      • Green W.R.
      • Traboulsi E.I.
      • Ma’luf R.
      Tick infestation of the eyelid.
      • Santos-Bueso E.
      • Calvo-Gonzalez C.
      • Diaz-Valle D.
      • Benitez-del-Castillo J.M.
      • Garcia-Sanchez J.
      Eyelid tick bite.
      The options for removal are either en bloc excision or removal with forceps. It is important to remove all residual tick parts because remnants are known to cause inflammatory or infectious reactions and increase the risk for transmission of certain zoonoses, particularly Lyme disease.
      • McLaren D.J.
      The cutaneous inflammatory response to parasite infestation.
      • Holak H.
      • Holak N.
      • Huzarska M.
      • Holak S.
      Tick inoculation in an eyelid region: report on five cases with one complication of the orbital myositis associated with Lyme borreliosis.
      Given the difficulty of whole-tick removal by forceps alone, we suggest that en bloc excision may be the preferred method because it confers definitive treatment and reduces the risk of expulsing tick contents, further exposing the patient to potential pathogens.
      It is important to consider antimicrobial prophylaxis following tick removal as well as counselling the patient regarding the symptoms of Lyme disease such as the development of a circular red rash and flu-like symptoms. Prevention of tick bites in endemic regions can also be promoted by wearing appropriate long sleeved clothing and the use of repellents.

      References

        • Keirans J.E.
        • Litwak T.R.
        Pictorial key to the adults of hard ticks, family Ixodidae (Ixodida: Ixodoidea), East of the Mississippi River.
        J Med Entomol. 1989; 26: 435-448
        • Cooley R.A.
        • Kohls G.M.
        The Argasidae of North America, Central America and Cuba, Monograph 1.
        The American Midland Naturalist. University of Notre Dame, Notre Dame, Ind.1944: 21-36
      1. The Connecticut Agricultural Experiment Station. Ticks of the Northeastern United States. Retrieved from www.ct.gov/caes/lib/caes/documents/publications/fact_sheets/TicksoftheNortheasternUnitedStates.pdf. Accessed November 29, 2014.

      2. Centers for Disease Control and Prevention. Geographic distribution of ticks. Retrieved from www.cdc.gov/ticks/geographic_distribution.html. Accessed November 29, 2014.

      3. Government of British Columbia. Ticks and Humans. Retrieved from www.agf.gov.bc.ca/cropprot/ticksbc.htm. Accessed November 29, 2014.

        • Samaha A.
        • Green W.R.
        • Traboulsi E.I.
        • Ma’luf R.
        Tick infestation of the eyelid.
        Am J Ophthalmol. 1998; 125: 263-264
        • Santos-Bueso E.
        • Calvo-Gonzalez C.
        • Diaz-Valle D.
        • Benitez-del-Castillo J.M.
        • Garcia-Sanchez J.
        Eyelid tick bite.
        Arch Soc Esp Oftalmol. 2006; 81: 173-175
        • McLaren D.J.
        The cutaneous inflammatory response to parasite infestation.
        in: Behnke J.M. Immunity and pathology. Taylor and Francis, Abingdon, U.K.1990: 193-194
        • Holak H.
        • Holak N.
        • Huzarska M.
        • Holak S.
        Tick inoculation in an eyelid region: report on five cases with one complication of the orbital myositis associated with Lyme borreliosis.
        Klin Oczna. 2006; 108: 220-224