When the OMNI Surgical System (Sight Sciences) entered the market, I was fortunate enough to have already developed MIGS techniques as it related to patients undergoing combination cataract and glaucoma surgery. Over the years, gaining the experiences of traditional canaloplasty (ab externo), as well as the evolution to ab interno, were valuable in making the transition to using OMNI. In our practice, we were treating many glaucoma patients who had undergone previous cataract surgery who were experiencing a noticeable decline in eye health due to glaucoma.
The belief, given our experience, was that we could achieve a similar pressure reduction in pseudophakic patients. OMNI, which combines two implant-free procedures—canaloplasty and trabeculotomy—and targets all three points of resistance, affirmed our belief. We discovered that we were able to achieve the appropriate pressure reduction without the need for invasive surgical processes, making this option extremely effective in patients with at-risk glaucoma conditions.
The OMNI Experience
In my hands, the OMNI procedure results in predictable IOP lowering and medication reduction and may obviate the need for invasive surgical procedures. For both the patient and surgeon, this is an attractive option. You can effectively reduce pressure through dilation of the natural outflow track, as well as exposure of the canal by unroofing the trabecular meshwork (TM).
In my experience, I observed that one cataract surgical element you don’t need for OMNI is a large incision. You can make a much smaller paracentesis in a pseudophakic patient. Additionally, after some experience, you can eliminate the need for an automated irrigation aspiration system and replace it with a basic balanced salt solution syringe or a washout. This approach doesn’t involve as much of the phacoemulsification equipment that is usually present when doing a combined cataract and OMNI procedure.
We have been pleasantly surprised with the results that OMNI can generate in pseudophakic eyes. Because OMNI targets all three points of resistance, it provides a solution for improving aqueous outflow dynamics, irrespective of whether the lens is removed in the same surgery.
Patient Case Study
The following case is an exemplary demonstration of how OMNI benefits pseudophakic patients.
- A man in his late 70s had been dealing with glaucoma for more than 30 years.
- He had undergone cataract surgery with an accommodative IOL before the advent of first-generation MIGS devices (the benefit of a pressure reduction at the time of his cataract surgery wasn’t available).
- He was prescribed three different IOP-lowering medications and had undergone selective laser trabeculoplasty (SLT) after his cataract removal.
- He enjoyed a short-lived modest improvement that ultimately digressed 10 years after cataract surgery.
- Three years after the SLT and with the patient on maximum medical therapy, the decision was made to address his rising pressure, and I opted for the OMNI procedure.
- We performed a 360° canaloplasty and 180° trabeculotomy in the morning and conducted the first postoperative exam later that afternoon (Figures 1 and 2).
- IOP dropped from the low 20s to 13 mmHg.
- The patient’s postoperative exam on day 5 had maintained the low 13-mmHg pressure.
- IOP level was recorded at every postoperative exam.
- IOP-lowering medications were reduced from three to one.
We were all pleased with this outcome, so we moved forward with treating the other eye with similar results.
Success With OMNI
To prepare to use the OMNI, simulation or cadaver eyes are a great option to start with. Both will help work out the timing needed to complete the procedures. When it comes time to offer OMNI as a treatment option in your practice, choose patients with an excellent pigmentation of the TM, which helps differentiate the anatomy and offers a wide-open angle. As well, during the procedure you’ll want to pressurize the eye to make sure the iris is back so you can maintain good visualization.
Using OMNI in pseudophakic eyes is similar to use in combined surgeries. In my experience, there are a few steps surgeons can take to ensure a meticulous surgery. For example, angling anteriorly about 10 to 20° helps to thread the catheter into the canal to effectively perform the canaloplasty as designed and avoid sliding over the scleral spur or entering the suprachoroidal space. Once the canal has been dilated 180° the catheter is reinserted and, while following the curvature of the canal, it is slowly retracted to unroof the TM. It takes a little practice, but all of the steps are well within the skill set of an anterior segment surgeon, and all steps are facilitated by gaining experience in moving the gonioprism to assure constant visualization while performing the procedure.
OMNI is applicable for post-cataract surgery glaucoma patients with mild-to-moderate disease. In my practice, OMNI reliably and predictably lowers IOP, as well as associated medication use, and it has the potential to avoid aggressive, incisional procedures. Surgeons with noted experience in gonioscopy and angle-based MIGS procedures will find a very natural process when moving toward OMNI, especially in pseudophakic patients. According to the International Agency for the Prevention of Blindness, glaucoma affects 80 million people globally and is one of the leading causes of irreversible blindness.1 Having the ability to address patients with mild-to-moderate glaucoma through a minimally-invasive OMNI procedure will dramatically affect how we treat glaucoma patients either during cataract operation or patients who’ve already received a replacement IOL.
1. The International Agency for the Prevention of Blindness (IAPB). Glaucoma. Available at: https://www.iapb.org/knowledge/what-is-avoidable-blindness/glaucoma. Accessed: September 4th, 2020.
OMNI® Surgical System
IMPORTANT PRODUCT INFORMATION:
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.
Do not use the OMNI® 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® 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 refer to the full Instructions For Use, available at omnisurgical.com, for warnings, precautions, and adverse event information.