Ординатура / Офтальмология / Английские материалы / Glaucoma Surgery_Trope_2005

either by shrinking the ciliary processes disrupting the ciliolenticular block or by causing thermal rupture of the adjacent anterior hyaloid membrane (59,65). The power employed varied from 100 to 300 mW. The duration of treatment was 0.1 s and the spot size was 100 200 mm. All patients were maintained on atropine after the laser application. Slight deepening of the AC may happen immediately after treatment but the full effect is delayed for 3 5 days. This laser procedure was also found effective by Weber et al. (66) in aphakic eyes, even without the use of cycloplegics.

5.4.Surgical Treatment

In cases of malignant glaucoma refractory to medical and laser treatments, one of the surgical approaches should be tried next. Historically, posterior sclerotomy [Weber (67)] and lens extraction (68 71) were used to treat malignant glaucoma. The success of the technique was attributed either to loss of vitreous (70) or to the incision made in the anterior hyaloid face (3,11). Chandler reported successful management with reformation of the AC by using air in one case of malignant glaucoma (72). Reformation of the AC should be attempted following poor response to medical therapy and prior to PPV. If the IOP is in single digits the AC can be reformed either by injecting a viscoelastic substance or, more effectively by injecting air, in addition to cycloplegics and aqueous suppressants administration. Air or viscoelastic injection forces the lens back and can break the vicious cycle. If the IOP is high, this technique will likely fail as air or viscoelastic is rapidly forced out of the AC through the surgical ostium. A large air bubble should be placed in the AC when performing this procedure to ensure the lens is pushed well back and the AC deepened.

5.4.1.Pars Plana Vitrectomy (PPV)

PPV is the preferred surgical technique for phakic, pseudophakic, and aphakic eyes, reflecting recognition of the central role of the vitreous in malignant glaucoma. The primary indication for PPV is failure of medical and other interventions (73). PPV is performed using a standard three-port technique and the major goal of this surgery is to disrupt the anterior hyaloid and reestablish the anterior aqueous flow. It is very important to instruct the retina surgeon to reform the AC at the end of the procedure preferably with a large air bubble.

The existing outcome data in the literature indicates that the success rate of PPV is generally better in pseudophakic eyes than in phakic eyes (Table 22.2). Failure of PPV in

Table 22.2 PPV Success Rate in Malignant Glaucoma

phakic eyes is mostly related to the difficulty in disrupting the anterior vitreous adjacent to the lens, without at the same time damaging the lens. In one series of patients [Byrnes et al. (74)], 30% of the operated patients developed cataract as a post-PPV complication. The success rate of PPV increases significantly in phakic eyes if lensectomy is performed. Lensectomy should only be performed in combination with PPV, in the presence of substantial corneal oedema or dense cataract or when the AC remains shallow despite PPV (73).

PPV, in general, appears to have several advantages over other surgical procedures (73):

1.PPV is a controlled technique, unlike Chandler’s technique (79) where a needle is directed blindly into the vitreous.

2.The risk of recurrent malignant glaucoma is minimized because the vitreous is removed and the anterior hyaloid face is disrupted.

The following are important steps during PPV that optimize the success rate of the procedure:

1.The presence of a patent PI should be always confirmed.

2.When placing the sclerostomies try to avoid prior filtration areas.

3.In phakic eyes, failure of the PPV in malignant glaucoma is related to incomplete vitreous excision from around the lens. Consequently, in every case of malignant glaucoma in phakic eyes, pupil dilation should be maximized to improve visualization for the vitreoretinal surgeon during the PPV. In small pupils with shallow AC, consideration should be given to mechanically stretching the iris after deepening the AC with a viscoelastic agent (74). It is also advisable that one sclerotomy site be made proximal to the PI, in order to improve visualization and avoid damaging the lens with the vitrectomy instrument [Byrnes et al. (74)].

4.The anterior hyaloid must be disrupted and any vitreous adhesions or capsular and zonular material behind the iridectomy sites removed (77), in order to establish unobstructed communication between the AC and the vitreous cavity.

5.Intraoperative deepening of the AC must always be visualized. This is usually consistent with long-term success without further surgery (73).

6.Medical treatment should be continued postoperatively for weeks or months. After the eye has been stable for several weeks following PPV, aqueous suppressants can be gradually withdrawn (see Section 5.2 of this chapter) but only under careful ophthalmic observation. Phakic patients should remain on cycloplegics postsurgery.

Complications of PPV for malignant glaucoma consist of cataract formation in 30% (phakic eyes) (74), retinal detachment in 9.5% (74), transient exudative retinal detachment in one eye (73), serous choroidal detachment in the range of 4.7 8.3% (73,74), corneal decompensation in 25% (73), and bleb failure in the range of 12.5 21% (73,74). The intraoperative development of suprachoroidal hemorrhage in one eye has also been reported (73).

Of significance is the fact that in cases of malignant glaucoma a successful PPV can be followed by failure of a previously filtering bleb.

5.4.2.Combined PPV and Pars Plana Tube Insertion

Azuara-Blanco et al. (80) reported the insertion of a pars plana tube (Baerveldt valve) with PPV in two cases of malignant glaucoma with a flat (from PASs) AC. This technique

successfully relieved the malignant glaucoma, controlled the IOP and prevented recurrence of this condition. This procedure may be an alternative surgical approach in cases with diffuse PASs and severe glaucomatous neuropathy (80) (see Chapter 21 in this book on methods to perform such surgery).

5.4.3.Chandler’s Technique

Chandler described a three-step surgical technique for malignant glaucoma, which was refined by him in 1968 because of the high rate of cataract formation in phakic eyes (71,79). This and similar techniques have been described (81). Chandler’s technique is still an alternative procedure if PPV is not available. Following are the steps that should be performed to ensure maximal success of the procedure.

Step 1: Confirmation of the Communication Between Posterior Chamber and AC. The presence of a patent PI must be confirmed before the patient enters the operating room. If there is no iridectomy present or if there is any doubt about the patency of the existing iridectomy, then another one should be created. If the AC deepens in the presence of a patent PI then the procedure is terminated.

Step 2: Corneal Paracentesis. Use a Wheeler knife or a similar instrument, to create a self-sealing beveled incision in the peripheral cornea.

Step 3: Sclerotomies to Explore for Suprachoroidal Fluid. Two sites in the two inferior quadrants of the eye are chosen as sclerotomy sites. The conjunctiva and Tenon’s capsule are opened. The sclera is then incised radially with a #15 blade. The scleral incision should be 3 mm in length and the center of the incision should be placed 3.5 mm posterior to the limbus (81). Precise placement of the sclerotomies is essential to provide access to the anterior vitreous face.

In the presence of suprachoroidal fluid, the AC is filled with BSS and the procedure is terminated if the AC deepens. In the absence of suprachoroidal fluid vitreous surgery should be performed.

Step 4: Vitreous Surgery. Prior to entering the vitreous cavity, diathermy is applied at the inner edges of the scleral wound, not directly to the choroid. An 18-gage needle is carefully passed through the sclerotomy, into the vitreous cavity to a depth of 12 mm, in the direction of the optic nerve head. Then the needle is gently moved from side to side in a 4 mm arc and 1 1.5 mL of fluid is aspirated followed by needle removal.

Step 5: Reformation of the AC. In addition, a large air bubble is injected in the AC to deepen the chamber to a depth greater than usually encountered. Finally, scleral and conjunctival wounds are closed with interrupted sutures. The use of atropine eyedrops should be continued postoperatively for several weeks or months.

Complications are almost always due to lack of attention to the details of the procedure. Hemorrhage can occur if diathermy is not applied around the sclerotomy wound. Retinal damage can occur if the needle is misdirected and not aimed at the optic nerve. Cataract formation can follow anterior placement of the scleral incision. A too posterior sclerotomy site results in failure of the procedure because the anterior hyaloid is not incised. Transient postoperative choroidal detachment and punctate retinal hemorrhages have also been reported that resolve spontaneously (81).

5.4.4.Alternative Surgical Procedures in Pseudophakic and Aphakic Eyes

Francis et al. (82) reported a slit-lamp needle procedure for the management of malignant glaucoma after trabeculectomy, in pseudophakic eyes. The procedure can be performed under topical anesthesia ( proparacaine hydrochloride eyedrops) through a single selfsealing corneal paracentesis. A paracentesis is made in the peripheral cornea adjacent to

212 Kourkoutas, Pavlin, and Trope

the iridectomy with a 27-gage needle. The needle is advanced through the iridectomy into the posterior chamber. The anterior hyaloid is then disrupted and a small amount of fluid is aspirated through the needle tip. Prior to withdraw the needle, the AC is reformed by air, BSS, or viscoelastic. This procedure was reported to be successful in two pseudophakic patients either by establishing fluid communication through the broken hyaloid face or by creating enough room for the AC structures to move posteriorly. The procedure is not meant to replace other therapies and was performed only after medical and laser treatment failed.

Recently, Lois et al. (83) described an alternative surgical approach to the management of pseudophakic malignant glaucoma via the anterior segment. Firstly, an AC infusion cannula is placed through a self-sealing peripheral corneal paracentesis, in the inferotemporal quadrant. Next, a similar beveled corneal incision is made 1 2 h from the preexisting PI or iridotomy and a vitreous cutter is introduced into the AC. The cutter is directed through the iridectomy and zonulectomy, hyaloidectomy, and anterior vitrectomy are performed. Thus, a communication between the AC and the posterior segment is established. The AC deepened intraoperatively. Using this technique, they effectively treated five cases of pseudophakic malignant glaucoma. The only complication reported was failure of a previously filtering bleb in one case. The advantages of this surgical procedure include the following: (1) Increased safety and lack of risks associated with PPV. (2) It is a simple procedure performed through the anterior segment making it an attractive therapeutic procedure for glaucoma/anterior segment surgeons.

Tsai and Tseng (84) suggested the use of combined anterior vitrectomy and trabeculectomy with mitomycin-C in pseudophakic eyes with malignant glaucoma and extensive PASs. Firstly, a conventional trabeculectomy with mitomycin-C is performed. Next, the vitreous cutter is introduced into the vitreous cavity through the internal ostium and the PI. An AC infusion Simcoe cannula is placed through a self-sealing peripheral corneal paracentesis, in the temporal quadrant. A partial anterior vitrectomy is performed via the PI similar to the process previously described by Lois et al. (83). This deepens the AC and establishes a communication channel between the AC and the vitreous cavity. Finally, the scleral and conjunctival flaps are closed as in conventional trabeculectomy. This procedure successfully relieved malignant glaucoma in one pseudophakic eye with extensive PASs and may be an alternative surgical approach to combined PPV and pars plana tube insertion introduced by Azuara-Blanco et al. (80). Moreover, it could possibly be used in cases of pseudophakic malignant glaucoma following conventional trabeculectomy, as vitrectomy via the anterior segment lacks of the risks associated with PPV and is technically simpler for the anterior segment surgeon to perform.

5.5.Fellow Eye

The presence of malignant glaucoma in one eye is a major risk factor for aqueous misdirection development in the contralateral eye (39). In order to provide a greater margin of safety for that fellow eye, precautions should always be taken in the pre-, intraand postoperative period as previously described.

Chaudhry et al. (85) suggested the use of prophylactic PPV during cataract surgery to prevent aqueous misdirection in high-risk fellow eyes. They reported one case that underwent combined prophylactic PPV, ECCE, and trabeculectomy with mitomycin-C and a second case that underwent combined prophylactic PPV and phacoemulsification. PPV preceded the cataract extraction and established an unobstructed communication between the vitreous cavity and the AC. Complications associated with PPV are well known and have been described elsewhere in this chapter (73,74). In addition, medical

treatment alone is effective in resolving 50% of the malignant glaucoma cases (5,11). Without further evidence, we feel prophylactic PPV should not be performed on eyes without malignant glaucoma.

6.CONCLUSION

Despite the fact that the pathogenesis of malignant glaucoma is not fully understood, there is good agreement that this condition is probably related to an abnormal anatomical relation among the ciliary processes, the lens, the zonules, and the anterior hyaloid. The vitreous plays an important role in the pathogenesis of aqueous misdirection. Choroidal expansion may be an additional causative factor in the pathophysiology of this condition but this needs confirmation. Recognition of eyes at risk and early diagnosis are critical for optimal management of this condition. The development of high resolution imaging techniques (UBM, slit-lamp OCT) is providing useful information. Management of malignant glaucoma is in evolution. Medical therapy resolves the condition in 50% of the cases. PPV is the preferred surgical technique for cases of malignant glaucoma that are unresponsive to medical therapy. Establishment of a direct and unobstructed communication between the vitreous cavity and the AC is important for optimal surgical success.

REFERENCES

1.von Graefe A. Beitra¨ge zur pathologie und therapie des glaucoms. Albrecht von Graefes Arch Ophthalmol 1869; 15(3):108 252.

2.Weiss DI, Shaffer RN. Ciliary block (malignant) glaucoma. Trans Am Acad Ophthalmol Otolaryngol 1972; 76(2):450 461.

3.Shaffer RN. The role of vitreous detachment in aphakic and malignant glaucoma. Trans Am Acad Ophthalmol Otolaryngol 1954; 58(2):217 231.

4.Levene R. A new concept of malignant glaucoma. Arch Ophthalmol 1972; 87(5):497 506.

5.Trope GE, Pavlin CJ, Bau A, Baumal CR, Foster FS. Malignant glaucoma. Clinical and ultra sound biomicroscopic features. Ophthalmology 1994; 101(6):1030 1035.

6.Liebmann JM, Weinreb RN, Ritch R. Angle closure glaucoma associated with occult annular ciliary body detachment. Arch Ophthalmol 1998; 116(6):731 735.

7.Luntz MH, Rosenblatt M. Malignant glaucoma. Surv Ophthalmol 1987; 32(2):73 93.

8.Hanish SJ, Lamberg RL, Gordon JM. Malignant glaucoma following cataract extraction and intraocular lens implant. Ophthalmic Surg 1982; 13(9):713 714.

9.Duy TP, Wollensak J. Ciliary block (malignant) glaucoma following posterior chamber lens implantation. Ophthalmic Surg 1987; 18(10):741 744.

10.Reese AB. Herniation of the anterior hyaloid membrane following uncomplicated intracapsu lar cataract extraction. Am J Ophthalmol 1949; 32:933 946.

11.Simmons RJ. Malignant glaucoma. Br J Ophthalmol 1972; 56(3):263 272.

12.Tomey KF, Senft SH, Antonios SR, Shammas IV, Shihab ZM, Traverso CE. Aqueous misdir ection and flat chamber after posterior chamber implants with and without trabeculectomy. Arch Ophthalmol 1987; 105(6):770 773.

13.Kodjikian L, Gain P, Donate D, Rouberol F, Burillon C. Malignant glaucoma induced by a phakic posterior chamber intraocular lens for myopia. J Cataract Refract Surg 2002; 28(12):2217 2221.

14.Chiou AG, Mermoud A, Hediguer SE. Malignant ciliary block glaucoma after deep sclerectomy: ultrasound biomicroscopy imaging. Klin Monatsbl Augenheilkd 1996; 208(5):279 281.

15.Greenfield DS, Tello C, Budenz DL, Liebmann JM, Ritch R. Aqueous misdirection after glaucoma drainage device implantation. Ophthalmology 1999; 106(5):1035 1040.

16.Weiss IS, Deiter PD. Malignant glaucoma syndrome following retinal detachment surgery. Ann Ophthalmol 1974; 6(10):1099 1104.

17.Massicotte EC, Schuman JS. A malignant glaucoma like syndrome following pars plana vitrectomy. Ophthalmology 1999; 106(7):1375 1379.

18.Ramanathan US, Kumar V, O’Neill E, Shah P. Aqueous misdirection following needling of trabeculectomy bleb [letter]. Eye 2003; 17(3):441 442.

19.Hardten DR, Brown JD. Malignant glaucoma after Nd:YAG cyclophotocoagulation [letter]. Am J Ophthalmol 1991; 111(2):245 247.

20.Cashwell LF, Martin TJ. Malignant glaucoma after laser iridotomy. Ophthalmology 1992; 99(5):651 658; discussion 658 659.

21.Small KM, Maslin KF. Malignant glaucoma following laser iridotomy. Aust NZ J Ophthalmol 1995; 23(4):339 341.

22.Mastropasqua L, Ciancaglini M, Carpineto P, Lobefalo L, Gallenga PE. Aqueous misdirection syndrome: a complication of Nd:YAG posterior capsulotomy. J Cataract Refract Surg 1994; 20(5):563 565.

23.DiSclafani M, Liebmann JM, Ritch R. Malignant glaucoma following argon laser release of scleral flap sutures after trabeculectomy [letter]. Am J Ophthalmol 1989; 108(5):597 598.

24.Weber PA, Cohen JS, Baker ND. Central retinal vein occlusion and malignant glaucoma. Arch Ophthalmol 1987; 105(5):635 636.

25.Kushner BJ. Ciliary block glaucoma in retinopathy of prematurity. Arch Ophthalmol 1982; 100(7):1078 1079.

26.Jacoby B, Reed JW, Cashwell LF. Malignant glaucoma in a patient with Down’s syndrome and corneal hydrops. Am J Ophthalmol 1990; 110(4):434 435.

27.Theelen T, Klevering BJ. Malignant glaucoma following blunt trauma of the eye. Ophthalmo loge 2005; 102(1):77 81.

28.Jones BR. Principles in the management of oculomycosis. XXXI Edward Jackson memorial lecture. Trans Am Acad Ophthalmol Otolaryngol 1975; 79(5):15 53.

29.Lass JH, Thoft RA, Bellows AR, Slansky HH. Exogenous nocardia asteroides endophthalmitis associated with malignant glaucoma. Ann Ophthalmol 1981; 13(3):317 321.

30.Rieser JC, Schwartz B. Miotic induced malignant glaucoma. Arch Ophthalmol 1972; 87(6):706 712.

31.Merritt JC. Malignant glaucoma induced by miotics postoperatively in open angle glaucoma. Arch Ophthalmol 1977; 95(11):1988 1989.

32.Schwartz AL, Anderson DR. ‘Malignant glaucoma’ in an eye with no antecedent operation or miotics. Arch Ophthalmol 1975; 93(5):379 381.

33.Fanous S, Brouillette G. Ciliary block glaucoma: malignant glaucoma in the absence of a history of surgery and of miotic therapy. Can J Ophthalmol 1983; 18(6):302 303.

34.Banta JT, Hoffman K, Budenz DL, Ceballos E, Greenfield DS. Presumed topiramate induced bilateral acute angle closure glaucoma. Am J Ophthalmol 2001; 132(1):112 114.

35.Medeiros FA, Zhang XY, Bernd AS, Weinreb RN. Angle closure glaucoma associated with ciliary body detachment in patients using topiramate. Arch Ophthalmol 2003; 121(2):282 285.

36.Postel EA, Assalian A, Epstein DL. Drug induced transient myopia and angle closure glaucoma associated with supraciliary choroidal effusion. Am J Ophthalmol 1996; 122(1):110 112.

37.Waheeb S, Feldman F, Velos P, Pavlin CJ. Ultrasound biomicroscopic analysis of drug induced bilateral angle closure glaucoma associated with supraciliary choroidal effusion. Can J Ophthalmol 2003; 38(4):299 302.

38.Hille K, Hille A, Ruprecht KW. Malignant glaucoma due to drug related angioedema. Am J Ophthalmol 2003; 135(2):224 226.

39.Chandler PA, Grant WM. Mydriatic cycloplegic treatment in malignant glaucoma. Arch Ophthalmol 1962; 68:353 359.

40.Quigley H, Friedman D, Congdon N. Possible mechanisms of primary angle closure and malignant glaucoma. J Glaucoma 2003; 12(2):167 180.

69.Rheindorf O. Ueber glaukom. Klin Monatsbl Augenheilkd 1887; 25:148 172.

70.Chandler PA. Malignant glaucoma. Trans Am Ophthalmol Soc 1950; 48:128 143.

71.Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol 1968; 66(3):495 502.

72.Chandler PA. Malignant glaucoma. Am J Ophthalmol 1951; 34(7):993 1000.

73.Harbour JW, Rubsamen PE, Palmberg P. Pars plana vitrectomy in the management of phakic and pseudophakic malignant glaucoma. Arch Ophthalmol 1996; 114(9):1073 1078.

74.Byrnes GA, Leen MM, Wong TP, Benson WE. Vitrectomy for ciliary block (malignant) glau coma. Ophthalmology 1995; 102(9):1308 1311.

75.Weiss H, Shin DH, Kollarits CR. Vitrectomy for malignant (ciliary block) glaucomas. Int Ophthalmol Clin 1981; 21(1):113 119.

76.Momoeda S, Hayashi H, Oshima K. Anterior pars plana vitrectomy for phakic malignant glau coma. Jpn J Ophthalmol 1983; 27(1):73 79.

77.Lynch MG, Brown RH, Michels RG, Pollack IP, Stark WJ. Surgical vitrectomy for pseudo phakic malignant glaucoma. Am J Ophthalmol 1986; 102(2):149 153.

78.Tsai JC, Barton KA, Miller MH, Khaw PT, Hitchings RA. Surgical results in malignant glau coma refractory to medical or laser therapy. Eye 1997; 11(Pt 5):677 681.

79.Chandler PA. A new operation for malignant glaucoma: a preliminary report. Trans Am Ophthalmol Soc 1964; 62:408 424.

80.Azuara Blanco A, Katz LJ, Gandham SB, Spaeth GL. Pars plana tube insertion of aqueous shunt with vitrectomy in malignant glaucoma. Arch Ophthalmol 1998; 116(6):808 810.

81.Epstein DL. The malignant glaucoma syndromes. In: Chandler and Grant’s Glaucoma. 4th ed. Williams and Wilkins, 1997:285 302.

82.Francis BA, Wong RM, Minckler DS. Slit lamp needle revision for aqueous misdirection after trabeculectomy. J Glaucoma 2002; 11(3):183 188.

83.Lois N, Wong D, Groenewald C. New surgical approach in the management of pseudophakic malignant glaucoma. Ophthalmology 2001; 108(4):780 783.

84.Tsai YY, Tseng SH. Combined trabeculectomy and vitrectomy for pseudophakic malignant glaucoma and extensive peripheral anterior synechia induced secondary glaucoma. J Cataract Refract Surg 2004; 30(3):715 717.

85.Chaudhry NA, Flynn HW Jr, Murray TG, Nicholson D, Palmberg PF. Pars plana vitrectomy

during cataract surgery for prevention of aqueous misdirection in high risk fellow eyes. Am J Ophthalmol 2000; 129(3):387 388.

Soltau (3) identified bleb leak as a significant factor for bleb-related infections. The focus of this chapter is on the management of bleb leaks.

2.CLINICAL QUESTIONS

Several questions must be asked when assessing a bleb leak:

1.Was there a precipitating event (recent trabeculectomy, eye rubbing, a blow to the eye)?

2.How ischemic is the appearance of the bleb?

3.Is the bleb infected?

4.What would the impact be if the bleb failed (severity of glaucoma, previous procedures)?

5.How damaged/inflammed is the surrounding conjunctiva?

These questions are essential in allowing us to determine whether conservative management is possible or aggressive surgical reconstruction is required.

3.CLINICAL DEFINITIONS

Bleb leaks may occur either early postoperatively or late postoperatively, even following a procedure by many years.

3.1.Early Bleb Leaks

Early leaks are usually due to imperfect closure or defective conjunctiva. Imperfect closure especially of a fornix-based flap often leads to a leak, but this usually spontaneously closes in 2 6 weeks as long as the scleral wound is well covered by the conjunctiva. If the leak persists beyond 6 weeks, we recommend closure of the leaking area with 8/0 vicryl or 10/0 nylon. If the conjunctiva retracts and exposes the scleral flap, the conjunctiva should be immediately undermined and resutured to peripheral cornea with a continuous 8/0 vicryl or 10/0 nylon suture. If during surgery a leak is predicted due to defective/buttonholed/friable conjunctiva, consideration should be given to aborting the use of anti-metabolite and establishing a tight scleral flap closure. Any buttonhole must be repaired at the time of surgery. Usually, the conjunctiva will heal spontaneously especially if the steroid dose is reduced and postoperative 5-fluorouracil can be given with subsequent suture lysis when appropriate.

3.2.Late Bleb Leaks

The management of late bleb leaks constitutes a more difficult and complex situation. The problem usually occurs when an anti-metabolite has previously been used and typically occurs with thin cystic blebs. The patient may complain of a teary eye especially on waking and fluctuating or decreased vision (due to hypotony). On occasion, however, the patient may present for routine follow-up with no symptoms and normal pressures, and only an index of suspicion on the part of the ophthalmologist will lead to detection of the leak. A simple Seidel test is all that is required.

Once a bleb leak has been identified, the three options of management are

(1) observation, (2) nonincisional maneuvers, and (3) incisional surgical repair.