Eyeworld

sponsored content Standalone MIGS and the Comprehensive Ophthalmologist Dr. Ahmed called the OMNI elegant and simplistic and discussed results when doing a standalone OMNI procedure. "If someone is on two medications, there's a good chance they'll be off one or both medica- tions, which is a success, and the pressures are often dropping into the low to mid-teens. That's my pressure target," he said. Dr. Ristvedt described a case of a 74-year-old pseudophakic female patient with primary open angle glaucoma who was on several medi- cations and was miserable. She had dry eye disease, chronic redness, irritation, and was struggling with fluctuating vision. Her visual fields looked fairly normal, and Dr. Ristvedt considered this patient to have mild glaucoma. However, the patient was becoming more intolerant of her drops, which impacted compliance. Dr. Ristvedt had a conversation with the patient about the option of MIGS to manage her pressure with the possibility of reducing or eliminating the need for drops. She used OMNI to perform a 360-degree canaloplasty and 180-degree trabeculot- omy. The patient was off of drops at the 1-week, 3-month, and 6-month postop visits, with a significantly improved ocular surface, which made the patient very happy. A benefit of surgical intervention, Dr. Ahmed noted, is treating the pathology, which flattens the diurnal curve, resulting in less peak pres- sure and potentially less progression. 1 "I think you did the patient a big service by being proactive and not waiting for her fields to change," he said about Dr. Ristvedt's case. When asked how she might have approached this patient in the past, Dr. Ristvedt said she likely would have tried more preservative-free medication. "I would have continued to explore different combination drop therapies, and I would have told her, 'We don't want you to prog- ress, so this is all we can do."' The introduction of MIGS procedures such as OMNI has lowered the threshold for surgical intervention such that it is being increasingly accepted as an early disease treatment option. Dr. Ahmed noted that cataract surgeons are used to referring glaucoma patients who aren't undergoing cataract surgery to a glaucoma specialist. Switching to a mindset of performing MIGS as a standalone procedure rather than referring the patient is a significant change. How- ever, he highlighted, if a comprehensive ophthalmologist is comfortable doing MIGS at the time of cataract surgery, he or she has the skill set to perform MIGS as a standalone procedure, too. Reference 1. Pyfer MF, et al. Suppression of diurnal (9AM–4PM) IOP fluctuations with minimally invasive glaucoma surgery: An analysis of data from the prospective, multicenter, single-arm GEMINI study. Clin Ophthalmol. 2021;15:3931–3938. Editors' note: The doctors in this advertorial have financial interests with Sight Sciences. T he glaucoma space has evolved to include various MIGS procedures, which offer less invasive options than traditional glaucoma surgeries. This surgical innovation has created an opportunity for comprehensive ophthalmologists to take a more engaged role in the surgical management of glaucoma patients. While MIGS is mostly combined with cataract surgery, many are starting to consider its use in standalone cases. This topic was discussed at the 2021 ASCRS Annual Meeting during a presentation in the ASCRS Tap Room sponsored by Sight Sciences, Inc. Before MIGS, conventional treatment options were limited to med- ications or trabeculectomy, with laser trabeculoplasty fitting somewhere in the middle, according to Ike Ahmed, MD, University of Toronto, Toronto, Canada. "MIGS came about to answer a need, and we focused on the setting of cataract surgery because it made sense," he said. "We were in the eye already with the opportunity to treat two diseases in a safe way." Deborah Ristvedt, DO, Vance Thompson Vision, Alexandria, Minne- sota, agreed that prior to MIGS, the options included medications, lasers, and invasive surgery. These were the only options for patients with mild to moderate glaucoma, so there was a huge unmet need, she noted. With glaucoma, Dr. Ahmed said, the eye is "always under threat," and though it may take time to manifest, time is important because of the irreversible nature of the disease. "We're seeing more and more evidence now that medicated patients don't do as well as patients who have laser or MIGS," he explained. Dr. Ahmed is also finding a reduction in trabeculectomies and tubes with earlier surgical intervention. While MIGS has largely been addressed in combination with cata- ract surgery, there are still many patients who can benefit from MIGS as a standalone procedure. Dr. Ahmed thinks one of the biggest untapped ar- eas in ophthalmology is the standalone pseudophakic glaucoma patient. Dr. Ristvedt shared that she gained confidence in performing MIGS with cataract surgery but also realized that she wasn't capturing all potential patients who may benefit from MIGS. "In my practice, MIGS works best when patients are in earlier disease," Dr. Ahmed said. "They last longer in those patients, and the success rate is higher." "If we can intervene early to reduce visual field loss and progres- sion, it's a win/win for everyone, and you're not bummed as a compre- hensive ophthalmologist that you waited too long," Dr. Ristvedt said. Speaking about the OMNI Surgical System (Sight Sciences, Inc.), Dr. Ristvedt highlighted the versatility of the device. "You can use it in combo cataract surgery, or you can use it as a standalone procedure," she explained. "It performs two procedures: a canaloplasty and a trabecu- lotomy to lower IOP in primary open angle glaucoma patients." Unlike OMNI's broad indication, the FDA has only authorized trabecular bypass stents for use in combination cataract procedures for mild to moderate cases, limiting their use to less than 15% of all POAG patients. 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. Contraindications: 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. Copyright 2022 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the staff and leadership of EyeWorld and ASCRS and in no way imply endorsement by EyeWorld and ASCRS. Sponsored by 2/22 OM-2162-US.v1

• Cover