How Do You Educate Patients and Set Expectations?

Ian Benjamin Gaddie, OD, FAAO: Significant advancements over the past decade have placed minimally invasive glaucoma surgery (MIGS) squarely in the mainstream of glaucoma management.

The OMNI Surgical System (Sight Sciences) is a next-generation MIGS technology that enables surgeons to target all three points of resistance in the conventional outflow pathway—the trabecular meshwork, Schlemm’s canal, and the distal collector channels—to restore normal outflow mechanisms. Between 50-75% of blockages may occur in the trabecular meshwork, with up to 50% possibly occurring in Schlemm’s canal and the distal collector channels.^1-3

Since the location of blockages can’t be determined, a procedure that addresses all potential points of resistance is needed. Available as a solo procedure or in combination with cataract surgery, the OMNI Surgical System performs a canaloplasty and trabeculotomy to address all potential resistance points.

The following summarizes our recommendations for educating patients about MIGS and the OMNI System, including the benefits of this procedure and what patients can expect postoperatively.

New Opportunity for Early Intervention

Dr. Gaddie: Let’s consider a hypothetical but typical case: a pseudophakic patient who has primary open-angle glaucoma and is using two topical medications, most likely a prostaglandin analogue along with another single-agent drug or a combination medication. The patient was treated with selective laser trabeculoplasty 2 years ago, and his visual fields now show evidence of progression. How would you counsel this patient?

Walter O. Whitley, OD, MBA, FAAO: Quality of life is a huge issue for patients who have glaucoma and are using topical therapies,⁴ and nonadherence is well-documented.⁵ While adding a drop may be an option in cases such as this one, we need to consider how topical therapies contribute to the burden of glaucoma, whether related to ocular adverse events, systemic side effects, or medication costs.^6,7

MIGS and interventional glaucoma therapies such as the OMNI procedure enable us to treat patients earlier in the course of their disease, especially mild to moderate glaucoma. The earlier we intervene and gain control of the IOP with targeted therapy, the better for our patients’ vision and their quality of life.

Justin Schweitzer, OD, FAAO: Interventional glaucoma is an important concept. If a patient’s disease is progressing, it makes sense to intervene surgically, but we never want to recommend a surgery that creates more risk of vision loss than the glaucoma itself. If a patient has mild glaucoma but is troubled by quality-of-life issues, a tube shunt or a trabeculectomy is not advisable. I believe MIGS with the OMNI System is a good option for this type of glaucoma patient.

Educating Patients About the OMNI Surgical System

Vin T. Dang, OD, FAAO: When describing MIGS as performed with the OMNI device, we first reassure patients that this procedure is as safe as cataract surgery.^8,9

We use a sink-and-drain analogy to explain that the OMNI device ‘unclogs the pipes’ to allow the aqueous to drain properly (Figure). This relieves the pressure that builds up when the outflow pathway or “drain” is blocked, thus reducing IOP.

For patients who appreciate hearing about clinical trials, I summarize research results. In the ROMEO study, Hirsch and colleagues reported that OMNI combined with cataract surgery in open-angle glaucoma patients demonstrated reduced IOP in patients with IOP greater than 18 mm Hg.¹⁰ The study showed an average IOP reduction of 6.8 mm Hg (from 21.9 mm Hg at baseline to 15.1 mm Hg at 12 months postoperative).¹⁰ There was also a medication reduction of 45%, with 33% of patients on zero medications at 12 months.¹⁰

In a similar arm in the ROMEO study with patients who received OMNI as a solo procedure, Vold and colleagues also demonstrated a reduction in IOP.⁹ There was an average IOP reduction of 6.2 mm Hg (from 21.8 mm Hg at baseline to 15.6 mm Hg at 12 months postoperative).⁹ There was also a medication reduction of 29%, with 38% of patients in the group on zero medications at 12 months.⁹

What Patients Can Expect After an OMNI Procedure

Dr. Schweitzer: Postoperatively, patients will be prescribed medications to minimize inflammation and infection. They should expect their vision to be somewhat cloudy or hazy, which is normal after any MIGS procedure, and this should resolve within a week.

Patients may be anxious about their eye pressures immediately after surgery, which is why it’s important to reassure them that IOP fluctuations will be the norm for a few months. Once their pressures stabilize, we will discuss any change in their medication regimen.

We know from the data that we can anticipate a reduction in the medication burden after an OMNI procedure. Patients who have mild glaucoma may potentially be able to eliminate a medication.

Dr. Whitley: MIGS with the OMNI device helps us regain control, and then we can adjust the medications as needed. In our practice, we stop the prostaglandin immediately after surgery and monitor the patient closely for any pressure changes. If there’s a spike, we adjust the medication.

Setting Up the Surgeon for Success

Dr. Schweitzer: The OMNI Surgical System utilizes a novel IOP-lowering approach, combining viscodilation of Schlemm’s canal and a trabeculotomy to restore patency to the conventional outflow pathway. As eye care providers, we need to understand this procedure to be able to prepare our patients for referral to a surgeon. Patients will appreciate that we took the time to discuss this with them, even if the surgeon ultimately decides to perform a different procedure.

The most effective referrals set up the surgeon for success and include:

• Confirmation of an open angle with gonioscopy prior to the referral
• Complete medical history, including current and past treatments
• Diagnostic test results, including OCT and visual field reports
• Details of quality-of-life issues the patient is experiencing
• Highlights of the referring doctor’s discussion with the patient about possible next steps, including the OMNI Surgical System.

Dr. Gaddie: The next frontier of medical optometry is helping our patients get to the appropriate surgeons for the appropriate procedures. Having a good relationship of mutual respect and understanding with a trusted ophthalmic surgeon enhances our ability to do this.