Background IgE plays an essential role in type I allergy, however there is less information about the relationship between other immunoglobulins (IgA and IgG) and atopic phenotypes in early childhood. Hypothesis We hypothesized that levels of circulating IgA in early childhood would be inversely related to the number of respiratory infections and the risk of becoming sensitized to allergens. Methods Immunoglobulin levels were analyzed (ELISA) in plasma samples (IgG, IgA), and in nasal secretions (IgA) from children participating in a high-risk birth cohort study. Samples were available from 264 children at age 2 years and 257 children at age 4 years, and results were compared to rates of respiratory illnesses, allergic sensitization, atopic dermatitis, and asthma. Results Children who were sensitized to allergens had higher rather than lower levels of circulating IgA. A subgroup analysis showed that IgA levels were increased in relationship to foods sensitization (58 vs. 50 mg/dL, p = 0.003) but not aeroallergen sensitization (52 vs. 53 mg/dL, p = 0.11). IgA levels in the plasma correlated with levels of IgE levels (rs=0.19, p=0.003). Levels of IgE, but not IgG or IgA, were positively correlated with rates of respiratory illnesses, atopic dermatitis, and the risk of developing asthma. Finally, there were no significant relationships between IgA in nasal secretions and infectious outcomes. Conclusions In conclusion, low-normal concentrations of plasma IgA are associated with a reduced prevalence of allergic sensitization in infancy. Further, levels of IgA and IgG in plasma within the range of normal, and IgA in nasal secretions, do not appear to influence the risk of subsequent respiratory illnesses. Further studies to define relationships between IgA and allergic sensitization are likely to provide new insights into the pathogenesis of allergic diseases in infancy.

Purpose: This interventional case report discusses inadvertent bilateral temporal globe penetration during placement of intramuscular wire electrodes to the lateral rectus muscles for intraoperative neurophysiological monitoring (IONM) via electromyography. Methods: An 11-year-old girl underwent surgical resection of massive medulloblastoma within the fourth ventricle, requiring IONM. Placement of an electrode in each lateral rectus muscle resulted in bilateral globe penetration, with choroidal rupture, retinal tears, and hemorrhage. Results: Sterile needle perforation of the globe did not result in endophthalmitis. Encircling laser retinopexy was performed, and no retinal detachments occurred. Conclusions: Insertion of needle electrodes without guidance imaging can potentially lead to globe penetration and incorrect electrode placement. Direct visualization with ultrasound, electromyography, or other advanced image-guided systems may offer a safe solution for electrode placement to avoid injury. Verbal patients should be made aware of postoperative warning signs of globe penetration. For nonverbal patients, a postoperative dilated exam is warranted.

Purpose: To present a patient with bilateral severe and symmetric lower lid lymphedema in the setting of previous neck surgery and chronic psoriasis, and to review the potential relationships of neck surgery, irradiation, psoriasis, and rosacea to chronic lymphedema. Design: Single case report with literature review. Methods: A 60-year-old female with long-standing psoriasis presented with a 2-year history of severe, symmetric bilateral lower eyelid edema that developed after total laryngectomy and selective right neck dissection for recurrent Squamous Cell Carcinoma (SCC). 10 years prior she underwent radiation and radical left neck dissection for metastatic disease. Surgical management entailed transcutaneous debulking of the masses combined with ectropion repair and suture tarsorrhaphy. A comprehensive literature review was performed using Pubmed and Medline. Results: Surgical debulking of the soft tissue masses via a transcutaneous incision resulted in significant improvement in the patient's lymphedema without recurrence at 5 months follow-up. Histopathologic findings were consistent with chronic eyelid lymphedema. Conclusions: Isolated eyelid lymphedema is rare, with many etiologies, and poses a diagnostic challenge. While ophthalmologists are familiar with the ocular manifestations of rosacea such as conjunctivitis or blepharitis, it is important to consider rosacea as an etiology of eyelid lymphedema. Reviewing the history for previous surgery or radiation to the head and neck, or other dermatologic inflammatory disorders is also warranted. Rosaceous lymphedema is typically less severe than in post-surgical/radiation patients, and does not respond well to medical treatment; however, it often shows a favorable response to debulking blepharoplasty surgery, with or without skin grafting. This patient with a history of severe psoriasis and bilateral neck dissections with radiation for SCC also responded well to surgery without recurrence of lymphedema. Therefore, surgical debulking can be considered in these patients with severe eyelid lymphedema as an option to markedly improve visual function and overall cosmetic appearance.

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