GLAUKOS Corp Q3 FY2023 Earnings Call

Hello, and welcome to Glaukos Corporation's Third Quarter 2023 Financial Results Conference Call. Copies of the company's press release and quarterly summary document, both issued after the market closed today, are available at www.glaukos.com. This call is being recorded, and an archived replay will be available online in the Investor Relations section at www.glaukos.com. I will now turn the call over to Chris Lewis, Vice President of Investor Relations and Corporate Affairs.

Thank you, and good afternoon. Joining me today are Glaukos Chairman and CEO, Tom Burns; President and COO, Joe Gilliam; and CFO, Alex Thurman. Similar to prior quarters, the company has posted a document on its Investor Relations website under the Financials and Filings Quarter Results section titled Quarterly Summary. This document is designed to provide the investment community with a summarized and easily accessible reference document that details the key effects associated with the quarter, the state of the company's business objectives and strategies and any forward statements or guidance we may make. This document is designed to be read by investors before the regularly scheduled quarterly conference call. As such, for this call, we will make brief prepared remarks and transition into a question-and-answer session. To ensure ample time and opportunity to address everyone's questions, we request that you limit yourself to one question and one follow-up. If you still have additional questions, you may get back into the queue. Please note that all statements other than statements of historical facts made on this call that address activities, events or developments we expect, believe, or anticipate will or may occur in the future are forward-looking statements. These include statements about our plans, objectives, strategies and prospects regarding, among other things, our sales, products, pipeline technologies and clinical trials, US and international commercialization, market development efforts, efficacy of our current and future products, our competitive market position, regulatory strategies and reimbursement for our products, financial condition and results of operations as well as the expected impact of general macroeconomic conditions including foreign currency fluctuations on our business and operations. These statements are based on current expectations about future events affecting us and are subject to risks, uncertainties and factors relating to our operations and business environment, all of which are difficult to predict and many of which are beyond our control. Therefore, they may cause our actual results to differ materially from those expressed or implied by forward-looking statements. Review today's press release and our recent SEC filings for more information about these risk factors. You'll find these documents in the Investors section of our website at www.glaukos.com. Finally, please note that during today's call, we will also discuss certain non-GAAP financial measures, including results on an adjusted basis. We believe these financial measures can facilitate a more complete analysis and greater transparency into Glaukos' ongoing results of operations, particularly when comparing underlying results from period to period. Please refer to the tables in our earnings press release available in the Investor Relations section of our website for a reconciliation of these measures to the most directly comparable GAAP financial measure. With that, I will turn the call over to Glaukos Chairman and CEO, Tom Burns.

Okay. Thanks, Chris. Good afternoon, and thank you all for joining us today. Today, Glaukos reported third quarter consolidated net sales of approximately $78 million, up 10% versus the year ago quarter. These third quarter results reflected continued strong performance and execution across our key franchises globally. Given these results and our latest forward outlook, we are raising our 2023 net sales guidance range to $307 million to $310 million versus $304 million to $308 million previously. From a commercial perspective, strong execution of strategies within each of our core franchises drove the solid performance. Within our US glaucoma franchise, we delivered sales of $38.1 million on growth of 2% year-over-year as we experienced more pronounced seasonality headwinds in August, offset by continued strength in July and September. Consistent with prior quarters, we continue advancing iStent Infinite ahead of establishing formal MAC coverage and payment. On that front, just last week, WPS, one of the 7 MAX, published an updated MIGS LCD with a future effective date of December 24, 2023, that provides coverage for iStent infinite consistent with FDA approval and our reconsideration request. We are pleased with the final outcome as it relates to iStent Infinite, but we're disappointed in other aspects of the LCD that severely restrict clinical decision discretion for surgeons fighting a site treating disease. Looking ahead, the remaining 6 MAXs have all taken preliminary steps to assess iStent if coverage, including four through proposed LCDs and two with local coverage articles. We continue to monitor the various MAC processes and policies as they advance and are ultimately finalized in the future as we remain supportive of expanding broad access to intervention of glaucoma tools for physicians and for patients. While we await the release of CMS' 2024 final rules, we remain encouraged that as part of the 2024 proposed rule the CPT code used to cover iStent Infinite in stand-alone procedures, 0671T was lifted to ABC-5492 and APC assignment for combined cataract plus trabecular bypass procedures, 66 989 and 66 991 was proposed to move to a newly restructured ATC-5493. If finalized as proposed, we do believe these changes, while positive for our customers and our procedures, may create some transient disruptions to ordering patterns in late 2023 ahead of becoming effective on January 1, 2024. Moving on. Our international glaucoma franchise delivered sales of $20.3 million on strong broad-based year-over-year growth of 23% on a reported basis and 20% on a constant currency basis. The strong growth was once again broad-based as we continue to scale our international infrastructure and execute our plans to drive MIGS forward as a standard of care in each region in every major market in the world. While we focus on our near-term execution, we are also accelerating efforts to support one of our founding missions at Glaukos which is to advance glaucoma care by driving intervention of therapies earlier in the treatment paradigm for glaucoma disease and, in turn, pioneering a new stand-alone market over time. We continue to lead and work closely with surgeons and thought leaders globally to organically drive this broader revolution in the standard of care, including through numerous events at the ESCRS annual meeting in Vienna in September and the interventional glaucoma consortium in Salt Lake City in October. These efforts will once again be on full display at the upcoming AAO Annual Meeting being held in San Francisco this weekend. And finally, our Corneal health franchise delivered record sales of $19.7 million on 12% year-over-year growth, including Photrexa record sales of $17 million on a year-over-year growth of 18% as key strategic initiatives implemented throughout the past year continue to take hold in support of this important business. Similar to our U.S. glaucoma franchise, our U.S. Corneal Health business experienced more pronounced seasonality headwinds in August, offset by strength throughout the remainder of the quarter. Shifting gears to the development front, we continue to prudently invest and successfully advance our robust pipeline of novel promising platform technologies that we believe have the ability to significantly expand our addressable markets and fundamentally transform our company over time. Starting with iDose. We continue to be encouraged as we work closely with the FDA in their ongoing NDA review process. During the third quarter, we successfully completed the required pre-approval inspection, or PAI, of our new state-of-the-art hybrid pharmaceutical manufacturing facility, notably with no 483 observations. For a company going through this type of rigorous pharmaceutical review for the first time, I could not be more pleased with this unblemished outcome and would like to recognize our operations, development and quality teams that drove this result. Based on our productive mid-cycle review meeting with the agency held in August, we remain confident in the agency's decision by the PDUFA date of December 22, 2023. Alongside this, our teams are increasingly advancing preparation and planning efforts to support the iDose commercial launch targeted for early next year, including a robust set of peer-reviewed literature expected to be published over the remainder of this year and into 2024. Our robust publication plan includes four manuscripts that have already been submitted to leading journals and at least five others that are planned for submission. Shifting gears to Epioxa, our next-generation corneal cross-linking therapy, we continue to advance patient follow-up in the second Phase 3 pivotal study and remain on track for our targeted NDA submission by the end of 2024. The iDose and Epioxa, we recently commenced a PMA pivotal study for iStent Infinite in the mild to moderate glaucoma population and expect to begin first-in-human clinical development for one of our retina programs along with a Phase 2a study for dilution Travoprost by year-end, respectively. So as you can see, we have a lot to be excited about when it comes to the significant potential value that we believe our pipeline programs may create. At the same time and as we have discussed, we continue to prioritize the cadence of our investments as we strive to strike the right balance of risk-based spending and our capital position now and in the future. We are pleased to see evidence of this again in the third quarter as our non-GAAP SG&A and R&D operating expenses grew at a modest 1% sequentially, reflecting some of the adjustments we've made in our earlier-stage pipeline programs as we continue to prioritize our resources ahead of the anticipated iDose commercial launch early next year. So in conclusion, I am pleased with the continued execution and performance in our business as we continue to successfully advance our mission to truly transform vision by pioneering novel Glaukos platforms that can meaningfully advance the standard-of-care and improve outcomes for patients suffering from sight-threatening chronic eye diseases. Our foundation is strong, and we are well positioned as we enter into what should be a transformational period for our company in the years ahead. So with that, I'll open the call to questions.

Perfect. Thank you. Our first question comes from the line of Tom Stephan. Tom, please go ahead.

Great. Hey guys. Thanks for the questions. I want to start off with the LCDs. Maybe if we assume the remaining formal MAC aligned with WPS, can you guys just talk first about the way the company from a strategic perspective is aiming to capitalize on any of the changes or just potential uncertainty that probably will ramp in the market next year? And then maybe qualitatively, how should we be thinking about any sort of net tailwind for Glaukos next year from LCDs?

Thanks for the questions, Tom. It's Joe here. I'll begin by addressing your inquiry. From a broader perspective, I want to emphasize some points that Tom mentioned in the prepared remarks. Firstly, regarding the recent LCD we've seen from WPS and our expectations for the other four MACs in a similar situation, the crucial aspect is the coverage for iStent Infinite. This has been our primary focus and effort to ensure that patients can access iStent Infinite as intended. Fortunately, WPS and hopefully the other LCDs will confirm the coverage we requested for iStent Infinite. However, we are disappointed because the current draft of the final LCD seems to diminish the clinical decision-making power of clinicians. This is something we will need to address moving forward, ensuring that surgeons retain the authority to make decisions for their patients. In terms of quantifying our outlook, we anticipate some short-term ordering fluctuations and challenges in December, particularly as some accounts might focus on non-stent procedures ahead of the finalized effective dates for various reasons. A significant factor will be reducing any inventory they have before policy changes take effect. Looking ahead to 2024, we're assessing the potential impact and will continue to monitor developments as other LCDs are finalized. I would advise investors to be cautious in the interim, as the WCS LCD includes many factors that affect our product portfolio, and we need to analyze everything comprehensively before providing detailed insights on its implications for 2024 and beyond.

Got it. And maybe one quick follow-up. When you talk about kind of the short-term volatility, are you starting to see that? Or I guess, what's informing that view? And then maybe I can get one more quick follow-up.

Yes, I wouldn't say that we're seeing it in that way. This is more of an anticipation thing. I think anytime you go into a change in reimbursement policy like that, and we've seen this in the past where things have adjusted. Obviously, the customers themselves have to adjust what their either treatment algorithms are, or the stock they have on their shelves, most are not going to sit around and hold that inventory past those effective days what you'd expect. And so as they get closer to that date, we certainly would anticipate that they'll use that inventory up, they'll go to more of a just-in-time ordering process, and then they'll adjust as the new year starts to unfold and they've changed whatever algorithm they have from a treatment perspective.

Got it. And maybe I'll call this question 2b. But pivoting to iDose, I wanted to ask about just stock trainings. Joe or Tom, any sense you can give us for how to think about the ramp in 2024? Will it be deliberate, methodical or early on as you work through establishing full reimbursement? And then what's a reasonable annual cadence of doctor trainings in the first couple of years as we refine our models. We look back at the iStent training ramp. There were periods early on that I think you trained 700, 800 physicians per year, nothing makes much less well-established. But now you have, what, 5,000 plus mix trained doctors. So for iDose, is it reasonable to think doctor trainings could approach 1,000 per year for the first couple of years? Thanks for talking the question.

No problems. I mean, struck three in for one, but we'll go ahead and honor it. it's all good. From a DUC standpoint, we're going to take the same approach we've always taken. And so I wouldn't say even just the beginning. I'd say for the entirety of 2024, we're going to be methodical as it relates to driving superlative outcomes in the case of the doctors that we're training on iDose. We've always done it that way. Now obviously, in those early days, let's call it, in the first half of the year, that will be even more the case and that we'll go out to a handful of surgeons that we know work well in these early-stage training situations, make sure that we've nailed down the training algorithm for our sales force before we start to expand from there. I think the other key gating item that I would point to as it relates to the pace of training is reimbursement itself. So as you transition from a miscellaneous code to a permanent code as you start to establish more regular and recurring payment on the professional fee, and even the facility fee side associated with iDose, more and more surgeons and their practices will be ready, willing and able to be trained. And so those things also play a role in this. You referenced historical statistics and they're accurate. I think at our peak, we were training somewhere between 700 and 800 docs a year on the iStent technologies, first generation, a lot of which was teaching them angle based surgery. As we move forward, I think that lift on the angle will be a little bit less. So we would have expectations that as we hit a steady run rate that we can train more doctors than that 700, 800 historical run rate with iDose. But to get more specific than that, it's hard until we really get at that stage of the deployment.

Very helpful. I'll keep it to one next time. Thanks guys.

Thanks.

All right. Our next question comes from the line of Ryan Zimmerman from BTIG. Ryan, please go ahead.

All right. I'm going to stick to the rules here and ask just one and the follow-ups. So number one, I'm going to ask for Tom. Tom, you're in the process, I think, of having conversations with FDA about labeling the iDose. I don't know what you're comfortable saying, but what can you say in terms of where you're at and the early read on what the label could look like for iDose?

Yes, Ryan. I'm happy to respond. As you mentioned earlier, this information is highly preliminary and is primarily based on our detailed briefing from the mid-cycle review we conducted midyear. I want to clarify that we have not yet received a draft label. While we are confident in the strength and robustness of our clinical data, we cannot be certain about the final label or how the FDA will interpret the data until that process is complete. We are optimistic about meeting the PDUFA date of December 22, but that's about as much certainty as I can provide at this moment.

Okay. Fair. We'll have to wait till the 22nd of December. Second question for me, just with the LCDs likely finalized from what we saw with WPS the other week, I'm less concerned with how this impacts your surgical business and more interested in how you think about derisking the iDose launch next year. So how does it change your calculus on iDose and what you need to achieve next year? I mean when we spoke kind of mid-quarter, your messaging that second half 2024 really would be the inflection for iDose, but I have to imagine that this takes some pressure off of the first half of the year because there is some benefit that will come from the LCDs. And so how has that in the past week, maybe shifted your thinking on the cadence for iDose next year?

Yes, Ryan. I’m not sure I would make that significant connection between the LCDs and iDose. The main factors for iDose in 2024 tie back to what I mentioned earlier. It will depend on how quickly we can train the doctors and establish reliable recurring reimbursements, especially related to facilities and professional fees. We need to transition past the initial phases of determining regular and consistent professional fees and ensure payments on the facility side. These factors will likely shift our progress from a slow start to a faster pace towards the latter half of the year rather than the first half. It’s possible that there will be increased demand across our portfolio for certain procedures, like stenting, but iDose might not see benefits from that until later in the year, moving into 2021.

Okay. Thanks for taking the questions.

Thanks, Ryan.

Our next question comes from the line of Larry Biegelsen from Wells Fargo. Larry, please go ahead.

Hi. This is Charles on for Larry. Thanks for taking the question and congrats on the nice quarter. I want to just follow up on the LCD again. So I appreciate you talked about there's puts and takes before and so maybe I wanted to follow up on to make sure you understand that positive negative of that. So on the positive side, I mean, iStent infinite and may be the competitive procedures like Canaloplasty, Goniotomy, maybe some of those stents pick up some of those. But on the negative side, it sounds like we read that sensor only covered as a second-line therapy the language seems to eliminate the stacking of multiple MIGS procedures. Are those the puts and takes you're talking about for first there, can you confirm that? And then I have a follow-up.

Okay. Yes, Charles, I think, first and foremost, anytime you have a policy like this, there's always some inherent ambiguity in it. That's the first line. I mean, I think exactly how the MAX will adjudicate these policy changes will matter over the course of the next several years. And that's hard to always know from the literal reading of a policy that comes out like this. So I think that's one factor that folks have to take into consideration. You referenced, obviously some of the adjustments that they are proposing or finalizing as it relates to canaliclasty, some of the shifts on the gondatomy side. When it comes to the combining of procedures, is correct, the WPS LCD does restrict the clinical decision-making as it relates to combining of these procedures. And we think it restricts the options that surgeons have and the fight against what's a multifactorial disease using tools that have complementary mechanisms of action. That is one of the puts and takes that have to be considered here. And certainly, is an offset to any pickup of share that you might anticipate associated with the restrictions that are being placed on canaloplasty and goniotomy and something that we're going to take our time to assess from an overall standpoint.

Thank you for your question. I want to follow up on LCD in relation to iDose. iDose specifically refers to LTV, but it seems they are seeking more comprehensive data, such as the 24-month published data for a broad label. Could you share when Glaukos expects to publish the 24-month data for iDose? Also, do you believe the Phase IIb data will suffice for the necessary qualifications, or is Phase III data required? Finally, if stacking is eliminated, would that imply that a physician could not perform an iStent along with iDose and receive coverage for it? Thank you.

I'll start, and Tom may want to comment as well. Regarding iDose, it's important to note that it is not covered by this LCD. It is a pharmaceutical and currently does not fall under the guidelines set by WPS. This is a separate topic that we need to consider. As you pointed out about the broader evidence, I believe that if we are fortunate enough to obtain approval, iDose will have more evidence supporting it at the time of its commercial launch than any product we've launched before. Tom has mentioned in previous calls the extensive number of peer-reviewed publications we anticipate, which will provide a comprehensive body of evidence, including the number of patients involved and the long-term data. We have already demonstrated multi-year evidence from our Phase II studies, and we expect to do the same from our Phase III study over time. Overall, we are confident that the evidence will stand up well against any requests from payers, including the MAX.

Yes, I would like to add that considering the Phase IIb data we have gathered over the past three years, it clearly demonstrates that 70% of patients are managing their condition with the same or fewer medications compared to the current standard of care, Timolol, which has a rate of 46%. The data is significant and solid, and we are confident that it will support our future discussions with payers for fair and timely reimbursement.

Great. That helps and again, congrats on a nice quarter.

Sure.

All right. Our next question comes from the line of Matthew O'Brien from Piper Sandler. Matthew, please go ahead.

Hi. This is Phil on for Matt. Thanks for taking our questions. For start is on glaucoma trends specifically, what was it about August that led to that pronounced seasonality? And how has that seasonality trending in Q4 and as it relates to guidance, what's baked into that sequential step down in revenue? Is it more a function of working down that competitive inventory ahead of these LCDs taking effect? Or is it really more a positive in front of CMS's final rule?

In the third quarter, we noticed that August may represent a new normal regarding seasonality, although it appears to be an anomaly compared to the previous couple of years. It seemed to align more with what we observed in 2019 regarding seasonality rather than the trends from 2020 to 2022. There was a general decrease in demand across all U.S. procedures, particularly in glaucoma and corneal health. However, we saw strong performance in both July and September, which has continued into October. When we consider our 2023 guidance, we account for various factors as we approach year-end. We anticipate potential short-term fluctuations in ordering patterns and challenges in December within our U.S. glaucoma franchise. This is related to the expected effective date of the final LCD and, as Tom noted earlier, the implications of the 2024 final CMS rule and the increased facility payments as we head into 2024. We believe there will be some disruption as providers may defer procedures at year-end to take advantage of more comprehensive payments in the first quarter. Additionally, we foresee some sequential foreign exchange challenges in our International Glaucoma Business, which could pose further headwinds in the fourth quarter. Furthermore, we may experience some ordering disruptions at year-end in our U.S. corneal health business due to several operational changes we will implement this quarter in preparation for a potential iDose launch in early 2024. These operational adjustments could affect aspects such as customer service and our payer relations team priorities, potentially causing some disruption on the cornea side as well.

That's helpful. And then just to give you one that doesn't focus on iDose. Can you speak further about that agreement with Stuart Therapeutics and maybe the timeline for that ST-113 drug candidate?

I’m glad to discuss that. Stuart has developed a novel compound that is still in the early stages of preparation, but we are encouraged by the data from the preclinical analysis. We are considering a bolus injection that could significantly enhance neuroprotection in glaucoma, which is a major challenge in preserving ganglion cells in the eye due to the increasing pressure from the condition. This proprietary compound is still in its infancy, but it is an exciting development for us as we aim to pioneer new treatment options for glaucoma. We are optimistic that this will lead to a significant clinical trial.

Thanks so much.

All right. Our next question comes from the line of Joanne Wuensch. Joanne, please go ahead.

Thank you very much for taking question and congrats on the quarter. I'd like to talk about something a little bit less exciting, which is expenses. I did not hear an update maybe on what you think your operating expenses could be. And then as you think about a product launch versus the time of the year that we start thinking about 2024, how do you sort of dovetail preparing and then launching everything that you've got in your pipeline, including iDose, not just this year but next. Thank you.

Hey, Joanne, this is Alex. I'll start by addressing the operating expense question. We were pleased to see the operating expenses for the quarter come in just shy of $87 million, which was only up modestly by 1% sequentially. We were happy with that. As we’ve discussed before, we’ve been focused on making initial adjustments to our pipeline in anticipation of iDose and reallocating our resources towards that while prioritizing our balance sheet and capital allocation. Regarding your question about the fourth quarter OpEx, I would guide you to expect a modest sequential increase in the fourth quarter compared to this quarter, which aligns with our historical trends, as the fourth quarter typically sees a rise compared to the third. This should bring our total for the year to around what we previously indicated, which is a little over a 10% increase from last year, excluding all of the IP R&D charges.

In response to your question, Joanne, I'm not certain if you were referring to expenses or overall planning. However, we have been focused on product launch planning for a significant amount of time. We are now delving into the details of what that entails from an expense standpoint as we prepare for next year, while also prioritizing other key areas. We have a lot happening, and we believe there are numerous opportunities ahead. We plan to invest significantly in iStent Infinite as we approach 2024, with the expectation of improved reimbursement coverage. Additionally, we will continue to support iDose on the commercial front while investing in what we believe is a strong pipeline of promising opportunities.

So just to push a bit, is the 10% increase annually in 2024, a reasonable starting point? Or is it much higher than that given everything else?

I think we'll comment on that, Joanne, when we get to the next quarter's call and we talk about our guidance in 2024 and what the operating expense profile would look like.

That’s all I got. Thank you.

All right. Our next call comes from the line of David Saxon from Needham. David, please go ahead.

Great. Good afternoon, guys and thanks for taking my questions. Maybe I'll start with a quick one on iDose. So you guys obviously completed the inspection and mid-cycle review in August. You mentioned a draft label. So when do you expect to receive that? And when you do, is that something you're going to share with the investment community and then aside from that, any other milestones to call out before December 22?

Hi, David, I'm happy to answer that. So we would expect to receive the draft labeling in the near term, let's call it, the next several days. And that begins the process, and that process is the FDA gives their best estimate of what they think the label should be based upon the data that they're reviewing. And then ordinarily and routinely, there is provision for response from the company to shape that label or to contest it to the extent that they disagree with the FDA's position. So there'll be a period of negotiation which will occur prior to the PDUFA date and the final, we hope, favorable FDA clearance. And I think as you can probably respect that, that will be something that will be done privately and that we won't share prior to the PDUFA date targeted clearance.

Thanks for the information. It seems there are no additional milestones after that. I also want to ask about the PreserFlo study mentioned in the document you shared. Is this study intended to address the concerns previously raised by the FDA? Additionally, what is your estimated timeline for potential approval of that product? Thank you.

I will gladly address your questions as best as I can. We've taken a novel approach to evaluating the safety and efficacy of the PreserFlo device, drawing from our considerable experience in this area. We have had discussions regarding this and are finalizing an IDE with the FDA. We are optimistic about reaching a successful conclusion that will allow us to commence the study in the early part of next year, certainly within the first half. This is a second opportunity for us, and with our expertise, we hope to achieve a successful outcome. While I cannot comment on specifics related to commercialization, such as adoption rates and clinical enrollment, I am confident that we will be able to start the study in the first half of next year.

All right. Thank you. And our next question comes from the line of Allen Gong from JPMorgan. Allen, Please go ahead.

Hi. Thanks for the question. I just had a quick one on the kind of iDose timing. I understand you can't really share the details of the mid-cycle review meeting, but you sound confident on the December timeframe. And I guess I was wondering relative to kind of your past attractions with the FDA, your past meetings like do you feel better or worse or roughly in line. I'm just asking because we've seen some FDA approvals getting pushed out and delayed with reasons that are kind of not visible to us on this side of the table. So just curious if there's any that you can provide and what gives you that kind of confidence?

Yes. I would be happy to provide the best assurances I can based on my current knowledge. After reviewing the situation and looking for any potential obstacles that might arise before we reach the final conclusion, I feel quite confident that we are on track for the FDA review date of December 22nd.

Got it. And then just another question. I understand that we don't want to talk about 2024 too much now. But when we just think about the growth of the MIGS market kind of XI dose, there's clearly been quite a few puts and takes over the last few years. Hopefully, 2024, there's going to be some bumpiness with the LCDs and the reimbursement changes. But how should we think about stable market growth going forward? Thank you.

Yes, Alan, I'm not sure that 2024 is perhaps the right measurement period because we're obviously going to be making our way through all the puts and takes associated with these shifts on the LCD front from the various MAX. I think we've certainly settled in that aside from maybe some of the moving parts there, that we're talking about an underlying market that continues to grow in a healthy fashion as MIGS becomes increasingly the standard-of-care in combination cataract. Our expectation would be that from a macro standpoint, that starts to accelerate in the coming years, again, as we drive our technologies, including iDose and iStent infinite into a much, much larger patient population that's served by the interventional glaucoma approach in stand-alone patients. So, I think 2024 may be a period where some things settle out in the context of what procedures are being done where the net effect of which, as we said, we'll comment once we've got some additional work done on that front. But overall, I think that we're headed to a more favorable environment from a MAC standpoint because we're going to be going after a much larger market.

All right. Thank you. And our next question comes from the line of Steven Litchman from Oppenheimer. Steven, please go ahead.

Hi guys, this is Ron on for Steve. Congrats on the quarter. I just wanted to ask another question on LCD, and it was just a short one, hopefully, since everyone else asked everything. I know following LCD, you can think about maybe as a net positive your competitors will probably lose much more business? Or do you guys see also a possible trade-off and as this LCD might shrink the market for maybe in general? And how do you guys think about this new balance? Thanks.

Yes, Ron, I believe that's central to some of the earlier responses. The trade-off we face is determining how much the LCD itself or similar LCDs may limit or impact the market in the short term. However, I don't think this will be as significant in the long term as we move forward with a larger patient population. In the short term, the focus is on market share relative to growth and how various factors will play out in 2024. We are confident that in the end, this should be at least neutral to slightly positive for our technologies due to the substantial evidence supporting them, which was affirmed as part of the LCD. However, it is challenging to quantify that at this point, especially with just one LCD released thus far in WPS.

Okay. And just one follow-up, and I think somebody asked about this on iDose is obviously, you guys can't market it yet, but will you be targeting or trying to promote it as an office-based procedure? Or is that something that is not part of the plan?

Hey Ron, I'm happy to address that. And so as we've said from the beginning, I think just philosophically, we're agnostic to where the product, the site of service is and where it's used. But we do understand, and there will be some advantages to moving into an in-office environment. And so, what our supposition and proposal will be there is to work with societies, work with the MACs over the course of 2024 into 2025 to create kind of a relative workup scale of what a non-facility payment should be and then get the MACs on board to be able to reimburse at that level. And so this will be an ongoing process. It is something that we'll be committed to over time, and we want to give surgeons the ability to have the alternative of doing the product within the ASC, which we expect will be the dominant use for some time into the in-office study. And then, I can assure you as well that we continue to work on developing programs that will continually aid our ability to move into that in-office facility.

Got it. Thanks guys.

Sure, Ron.

All right. Thank you. And our next question comes from the line of Anthony Petrone from Mizuho Group. Anthony, please go ahead.

Thanks and congrats on a good quarter and a good momentum. Maybe just two quick ones, one on iStent Infinite, one on iDose. On iStent Infinite, you mentioned in your prepared comments here on the quarter that you have a mild to moderate label expansion study going on. And so how large is that study? When will it be completed once we see data on that? And then quickly on iDose, when we think about label, what should we be thinking about in terms of just duration of implant, right? So the pivotal study at a three-month primary endpoint, you had a 12-month secondary endpoint that the company, I believe, has data out to five years. So how should we be thinking about just the range of scenarios on duration of the implant for iDose? Thanks.

To address the first part of your question, yes, we have initiated the clinical study for the iStent Infinite. We made the decision to advance this product into earlier stages of intervention and treatment to enhance our overall interventional glaucoma philosophy and program. The protocol will include both phakic and pseudophakic patients classified as having mild to moderate open-angle glaucoma. We now have a label that positions iStent Infinite for patients who have not had success with prior medical and surgical therapies. This opens up the potential for using iStent Infinite in the initial phases of glaucoma treatment and provides a complementary and combined option alongside the iDose device. Could you please repeat your second question?

It would be on duration of implant and label for iDose, you have your primary study at a three-month endpoint, you had a 12-month secondary end point, but I believe the company has referenced data on the implant out to five years. So there's a wide range of scenarios there. Just any high-level thinking on what the duration of the implant for iDose could be?

Yes. Let me address that again. Happy to. Remember, the primary efficacy endpoint and the basis for our approval will be a three-month determination of the iDose to show non-inferiority versus topical theme and you've seen the data. And I think we can all agree that we have a high degree of confidence that at least we'll have a reasonable argument to assure FDA approval moving forward. There is no longer-term pivotal endpoint for the high-dose device. What we've done prior to the FDA pivotal was to conduct this robust Phase II data that we carried out to three years. That will be the basis for how we'll approach payers for how well this product works longer term. And I think we'll be assured that, that data, I think payers will be assured with that data that the product does indeed provide substantive coverage for patients all the way out to three years. When you talk about the five-year data remember, that was a cold set of patients from the Phase IIb study that were exchanged. So 33 patients where we pulled from that, the reconsented to have an exchange of the iDose device. And it was there that we came up with some pretty pristine data on endothelial cell loss to show that the exchange can be done with reasonable safety and security.

All right. Our next question comes from the line of George Sellers from Stephens. George, please go ahead.

Hey. Good afternoon. And thanks for taking the question. Maybe just one quick one for me. But could you just remind us thinking back to 2022 and the end of 2021, how your market share of MIGS procedures in the US shifted some reimbursement changes. And do you have a sense for where that share went?

George, it's Joe. I mean, if you look back at our results in 2022 on our US glaucoma franchise pretty consistently every quarter, we were down about 15% on a year-over-year basis. I think that gives you a pretty good sense of at least in that time period, the share shift that occurred. Beyond that, I don't have the data in front of me in terms of where that went, but I would say that the lion's share of that went to some combination of either canaloplasty procedures or goniotomy procedures depending upon surgical preference.

Okay. Great. Thanks for that color. And I'll leave it at just one. Thanks all for the time.

Thanks, George.

Thanks, George.

All right. At this time, there are no further questions. I'll turn it back over to the company.

Okay. So I want to thank all of you again for your time and attention today, and we always thank you for your continued interest and support of Glaukos. So with that, goodbye.

That does conclude today's call. Have a pleasant day.