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 .