Finding a tick in the eyelid is rare but can occur after exposure to tick-infested areas. In this Inside Lyme Podcast case study, I review the removal of an engorged deer tick embedded in the eyelid of an 8-year-old girl.
I often find that the best way to understand Lyme disease and other tick-borne infections is by reviewing real clinical cases. In this episode, I discuss how physicians safely removed a tick deeply anchored in the eyelid.
Jaroudi and colleagues described this unusual case in the journal Case Reports in Ophthalmology in 2020.
“The patient’s mother reported noticing a small foreign body protruding from her daughter’s eyelid which gradually increased in size over the course of five days,” wrote Jaroudi and colleagues.
A slit-lamp examination revealed a large tick deeply embedded in the girl’s right upper eyelid. The child had visited an animal farm several days earlier during a school trip.
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Physicians removed the deer tick using a surgical approach. “Our surgical approach included total excision of the tick with the attached eyelid tissue,” the authors wrote. The procedure involved removing a small portion of eyelid tissue along with the engorged tick.
The pathologist later identified the parasite as an Ixodes species—commonly known as a deer tick—the same tick responsible for transmitting Lyme disease in the United States.
In an open-access article, the authors included photographs showing a markedly engorged tick embedded in the eyelid. The images also showed swelling around the eye and eyelid ptosis, a condition where the upper eyelid droops over the eye.
The case report and images are available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940453/.
In endemic regions of the United States, the risk of Lyme disease transmission from an engorged tick may reach approximately 20%. Because ticks are blood-feeding parasites capable of transmitting bacteria, viruses, and rickettsial infections, the authors emphasized the importance of considering antibiotic prophylaxis after tick removal.
At the time the tick was removed, there was no evidence of Lyme disease or co-infection. The physicians treated the girl prophylactically with oral amoxicillin for ten days.
Why Careful Tick Removal Matters
The authors explained their decision to surgically excise the tick and a small portion of eyelid tissue. Physicians have long been concerned that compressing the body of a tick during removal may increase the chance of regurgitation of infectious material into the wound.
The authors were also concerned that the tick’s hypostome (mouthparts) could remain embedded in the skin, potentially leading to granuloma formation.
They described the classic method for removing a deer tick:
- Avoid unnecessary manipulation of the tick
- Grasp the tick’s mouthparts firmly as close to the skin as possible
- Clean the skin thoroughly after removal
The authors also noted that certain removal methods may increase the risk of regurgitation of infected material. These include applying heat to the tick or attempting to smother it with substances such as petrolatum.
What can we learn from this case?
- Careful removal of a tick is essential.
- Surgical excision may be necessary when a tick is deeply embedded in sensitive areas such as the eyelid.
What questions does this case raise?
- What is the best treatment after a tick bite to prevent infection? In this case, the child received ten days of amoxicillin. I remain uncomfortable with the single 200-mg dose of doxycycline recommended by the Infectious Diseases Society of America (IDSA). In my practice, I typically treat for three to four weeks with follow-up to ensure a good outcome.
- Is the child at risk of developing a co-infection not covered by amoxicillin? Amoxicillin does not treat infections such as Ehrlichia, Anaplasmosis, or Babesia.
- Could the child develop chronic illness following the tick bite? Studies suggest that a significant portion of individuals with Lyme disease may continue to experience persistent symptoms.
Preventing Tick-Borne Disease After a Tick Bite
Cases like this highlight the importance of prompt recognition and careful removal of ticks. Early medical evaluation after a tick bite may help reduce the risk of Lyme disease and other tick-borne infections.
