Minimally invasive glaucoma surgery (MIGS) has undoubtedly changed the way glaucoma is managed in the office. The safety profile associated with this new category of stents, drainage augmentation, and other procedures makes them suitable options for use earlier in the disease continuum, offering the potential to help patients secure greater intraocular pressure (IOP) control while gaining independence from topical medications.
The good news for patients is that the pace of innovation in MIGS continues to accelerate, including new devices and interventions coming to market, as well as subtle changes to how current MIGS is used in real-world practice. The growing popularity of MIGS for pseudophakic patients—MIG surgery uncoupled from cataract surgery—is one such development that is poised to alter glaucoma management for the better.
As surgeons across the United States contemplate offering MIGS for their pseudophakic glaucoma patients using the OMNI® Surgical System, Sight Sciences engaged with early adopters to learn why and how they integrated this new approach into their practices.
Surgeons Jai G. Parekh, MD, MBA, and Swati J. Parekh, MD, of EyeCare Consultants of New Jersey, along with their associate Payal P. Ramakrishnan, OD, FAAO, and members of their OR team, recently sat down to share their insights on how they are incorporating MIGS with OMNI for pseudophakic patients into their practice.
Goal: Fulfill an Unmet Need
“We've always been innovators in our practice,” Dr. Jai Parekh said. “We look at our patients’ unmet needs and then look for technologies in the marketplace that may fulfill those needs. Offering OMNI for pseudophakic patients fits in well with our practice philosophy, as it gives many more patients the opportunity to benefit from this minimally invasive surgical intervention.
“As anterior segment surgeons, we have been performing MIGS at the time of cataract surgery for many years, and as we became comfortable with this surgery, we realized that there are still many patients who could benefit from a MIGS procedure performed outside of cataract surgery," Dr. Jai Parekh said. "We now find ourselves in an interventional glaucoma space where it's important to look at that unmet need and offer really cool, efficient technology to take care of these patients. For us, it was an easy transition to adopt MIGS for pseudophakic patients using the OMNI Surgical System.”
About the Technology
The OMNI Surgical System is the only MIGS technology that is indicated for canaloplasty followed by trabeculotomy to reduce IOP in patients with primary open-angle glaucoma. It is one of two implant-free MIGS with an indication for pseudophakic patients. Because there is no diagnostic to determine where resistance is located in the conventional outflow pathway, OMNI is well suited to address the three primary areas of resistance—the trabecular meshwork, Schlemm’s canal, and the distal collector channels.
“We know that mild to moderate glaucoma progresses, and often there are obstructions and herniations in the canal,” Dr. Jai Parekh said. “Performing MIGS with OMNI to help reduce resistance in those three areas has been really effective.”
Dr. Swati Parekh noted, “With OMNI, we can treat patients earlier in the disease process, during the disease, and even later in the disease."
Candidates Identified
Candidates for MIGS with OMNI are patients who have already undergone cataract surgery, possibly including other MIGS. These patients may be experiencing glaucoma progression despite seemingly controlled IOP. Some may be noncompliant with their medications, or they may not be reaching their desired target pressure using drops alone.
“Some of these patients may have had SLT or received an intracameral biodegradable implant, and now they need something else,” said Dr. Jai Parekh. “We also have pseudophakic patients who may have had MIGS in combination with their cataract surgery, and now they are several years out and needing additional intervention. MIGS with OMNI addresses the unmet need for all of these patients.”
In discussions with her glaucoma patients, Dr. Ramakrishnan often identifies potential candidates for MIGS with OMNI, including patients who are in their sixties or seventies who have had cataract surgery. “Compliance is often a concern for these patients,” Dr. Ramakrishnan said. “They may have arthritis and cannot administer their drops. Some may have ocular surface toxicity from the preservatives in the drops causing them to not use their drops as prescribed. There are a variety of cases where MIGS with OMNI is a viable option.”
Key Messaging for Patients
When Dr. Ramakrishnan counsels patients who are candidates for MIGS with OMNI, she focuses on the benefits of this surgery.
“I educate our patients that this procedure will increase their chance of having a more consistent IOP reduction compared to using their eye drops,” Dr. Ramakrishnan said. “There may be patients who are not using their drops as directed and don’t understand the potential vision loss this can cause. I stress that skipping just one day out of seven can slowly, over time, impact their glaucoma and cause the disease to progress to a more advanced stage.”
Dr. Swati Parekh has noticed something of a dichotomy in the reactions of patients when she introduces the idea of MIGS with OMNI.
“Many of our patients have been using medical treatments for a long time,” she said. “So, when they hear ‘surgery,’ there are two distinctly different reactions. Some patients feel apprehensive, while others are relieved to hear that there is an implant-free and comprehensive surgical option. They have a sense of technology and feel that this is a more direct approach versus medical treatments.”
Dr. Swati Parekh said some patients feel discouraged when they’re told they need to increase their medications because their IOP is not at target or their disease is progressing on their current treatment regimen.
“They think, ‘Here's one more thing that I have to do,’” she said. “Whereas, when we offer or at least have an option of something surgical, they feel their doctor is helping them, that it’s not just up to them. When we offer a minimally invasive surgical option, suddenly we are partners with our patients again.”
There’s also a matter of trust, Dr. Jai Parekh said.
“Initially, patients may say, ‘I don't want a one-hour operation.’ Then, we explain that this is a glaucoma procedure with the goal of reducing their IOP, and it’s performed very efficiently and has great outcomes.1 Patients are very much attracted to that, and they have a great deal of trust in us as their glaucoma doctors. When we explain MIGS with OMNI in this way, patients truly embrace it.”
Engage Your Team
While the overall benefits of MIGS are well known, integrating OMNI for pseudophakic glaucoma patients into the office and the operating room requires some practical preparations, starting with the personnel who will be involved in all aspects of delivering care.
“No surgeon is successful without a supportive team behind him or her,” Dr. Jai Parekh said. “After deciding to incorporate MIGS with OMNI for pseudophakic patients, I made it my first priority to discuss this new service with our staff to make sure everyone understood that we would be using an existing technology as a standalone procedure, independent of cataract surgery.
“It’s easy for me to tell patients we’re going to perform MIGS with OMNI for pseudophakic patients,” he continued, “but it’s incredibly important to engage my surgical coordinator, my planner, and our manager to ensure that each surgery is booked efficiently in the operating room, whether a hospital or surgery center. That communication is essential to keep our process patient-centric from the time patients see the surgeon at the slit lamp and throughout their journey.”
Minimal Learning Curve
“Whenever we incorporate an innovation, there's going to be a learning curve, not just for the surgeon, but also for the people who help the surgeon become successful in integrating that innovation into patient care,” Dr. Jai Parekh said.
“Once I identified the patients and the unmet need, and after having the ability and comfort of performing MIGS for many years during cataract surgery, putting it into a system for pseudophakic patients was quite easy,” he said. “Nevertheless, it took a village because, for the most part, many of our patients were administering drops, had MIGS during cataract surgery, or they had SLT to treat their glaucoma. Now we are introducing another category. For us, it's been an exciting addition, and one that the patients and their families appreciate, as well as the people in the office and in the operating room who are taking care of them.”
According to Surgical Nurse Manager Meena Devi, DNP, “Introducing a new surgery or procedure can be challenging. It’s important for staff members to understand the benefits and why we are doing it,” she said. “Dr. Jai Parekh was able to explain this new approach to me and my staff in such a way that everyone understands why we are doing MIGS with OMNI for pseudophakic patients and what each staff member’s role is. When everyone thought about the patient perspective—how reliable this surgery will be for those patients and how much they will benefit from the outcomes—my staff was ready to get on board, and we were able to work out the process.”
A MEANINGFUL ADVANTAGE: REDUCED MEDICATION BURDEN
It’s important not to underestimate the value of reducing a patient’s medication burden, an advantage that OMNI for pseudophakic patients can offer.1
As Dr. Jai Parekh noted, “It’s incumbent upon us as good eye care professionals and surgeons to offer our patients innovations that occur in the market, to identify the unmet need, and to apply an intervention to help solve it.
“That said, I think treating glaucoma patients only with drops is a mistake. That is a huge unmet need. For many patients, polypharmacy is an issue, as is ocular surface disease; cost and the physical burden of administration can be issues. It's important for all of us in the community to embrace OMNI for pseudophakic glaucoma patients as an important aspect of interventional glaucoma to help address these concerns.
“In our practice, we love using the OMNI® Surgical System, which encompasses both canaloplasty and trabeculotomy. It has the advantage of addressing all three areas of resistance, opening the conventional outflow pathway to reduce IOP, and potentially reducing a patient’s medication burden.”
OR Efficiency
“In the operating room, MIGS with OMNI is somewhat different from cataract-only surgery and combined cataract MIGS,” Dr. Jai Parekh said. “Number one is the throughput time, getting people in and out of the operating room in an efficient, safe manner. To achieve this efficiency, we’ve coached everyone inside and outside the operating room, including the pre-op and post-op areas.”
In his role as surgical technician, Lowell Martin, CST, has recognized some of the benefits of OMNI for pseudophakic patients in the operating room.
“From my perspective, OMNI for pseudophakic patients is simpler than cataract MIGS,” Mr. Martin said. “Irrigation/aspiration and phacoemulsification setup are eliminated. I use only syringes, just BSS and incisional and ophthalmic viscosurgical devices (OVDs). The benefits are efficiency, as there’s less anesthesia and less instrumentation, and the room turnovers are very quick, an advantage for the whole team.”
Scheduling Notes
To ensure efficiency when integrating OMNI for pseudophakic patients into an already busy schedule, EyeCare Consultants of New Jersey instituted block scheduling to designate a specific time frame for these cases.
“In my OR, OMNI for pseudophakic patients is its own entity,” Dr. Jai Parekh said, “and our nurses and managers at all three centers know what it's going to take to book these patients to maximize turnaround time and efficiency.
“We schedule these cases consecutively for the first few cases in the morning,” Dr. Jai Parekh explained. “Then we take our cataract MIGS cases followed by our cataract-only cases. This system ensures that everyone—the anesthesiologists, the nurses, and the scrub technicians—is efficient and focused on OMNI and a little bit of OVD during that portion of the morning. By doing this, we’ve had amazing buy-in from all of the stakeholders, as well as our patients and their families.”
A Seamless Process With Great Rewards
Implementing OMNI for pseudophakic patients at EyeCare Consultants of New Jersey has not been difficult, Dr. Jai Parekh said. In fact, doing so has helped him and his team realize improved efficiency and patient flow through the OR. Identifying appropriate candidates is simply a matter of identifying the best option for each individual patient, something that ophthalmic surgeons are already doing on a daily basis.
Dr. Swati Parekh noted there is a benefit to surgeons as well. “Being able to offer OMNI for pseudophakic patients really empowers us as physicians because it enables us to be a more integral part of the patient's journey to guide them toward achieving their target,” she said.
Dr. Jai Parekh offered the following advice to physicians who are still considering implementing OMNI for pseudophakic glaucoma patients.
“I encourage all of my colleagues in the community, both ophthalmologists and optometrists, to take note. Candidates for MIGS with OMNI are in your waiting room. Many are patients who had cataract surgery years ago. They’re not meeting their target pressures. Their disease may be progressing. They have ocular surface disease. They have issues related to polypharmacy. They may even have physical limitations.
“Wouldn't it be cool to take these patients who are struggling to manage this lifelong disease and apply an intervention to help care for them on their journey? That's the mindset we've incorporated in our practice over the last year. These are patients who otherwise might have become blind because of poor pressure control. To be able to take a patient to the operating room to perform MIGS with OMNI has been a true game-changer for us.
“As surgeons, we always think about how we could have done things better,” Dr. Jai Parekh added. “My only regret is, I wish I had offered OMNI for pseudophakic patients years ago.”
1. Williamson BK, Vold SD, Campbell A, et al. Canaloplasty and Trabeculotomy with the OMNI System in Patients with Open-Angle Glaucoma: Two-Year Results from the ROMEO Study. Clin Ophthalmol. 2023;17:1057-1066.
INDICATIONS FOR USE: The OMNI Surgical System is indicated for canaloplasty (microcatheterization and transluminal viscodilation of Schlemm’s canal) followed by trabeculotomy (cutting of trabecular meshwork) to reduce intraocular pressure in adult patients with primary open-angle glaucoma.
CONTRAINDICATIONS: Do not use the OMNI Surgical System in any situations where the iridocorneal angle is compromised or has been damaged (e.g., from trauma or surgery), since it may not be possible to visualize the angle or to properly pass the microcatheter. Do not use the OMNI Surgical System in patients with angle recession; neovascular glaucoma; chronic angle closure; narrow-angle glaucoma; traumatic or malignant glaucoma; or narrow inlet canals with plateau iris. Do not use the OMNI Surgical System in quadrants with previous MIGS implants. Please visit OMNISurgical.com/ifu for the full instructions for use, warnings, precautions, and adverse event information.
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