George Sellers: Maybe sticking with the iDose theme, could you just provide some additional color on maybe where you’re seeing early utilization in the first quarter and also quarter to date here in the second quarter, if that’s in conjunction with a stenting procedure or another MIGS procedure? And then also what stage of the disease progression these patients who are receiving an iDose are?
Joe Gilliam: I think at this point, when you’re early in a product launch like this, you try to keep it as simple as possible. The more variables you introduce, the more challenging it becomes in terms of both education of the sales force as well as for the accounts and execution on there. And so as you know and as we’ve said in the past, the primary goal there is for clean standalone utilization of iDose. Now having said that, have we seen surgeons for clinical reasons do it either in combination with cataract surgery or in combination with iStent infinite? The answer is yes, we have based upon the clinical needs of those patients. And so we will continue to monitor that and bring it forward. So I think we’re really thinking very close to the playbook that we had prescribed as we drive this forward and we’ll continue to see surgeons expand the use case of iDose to go forward.
Utilization itself and the trends associated with it very different from account to account. Those accounts who have experience in billing miscellaneous codes, we’ve seen them really start to utilize iDose more fulsomely. For those with a little less experience, they’ll start, they’ll try, they’ll do a handful and then wait for the payments to pull through before they green light that broader adoption.
George Sellers: And then maybe going back to a prior question on this call. How should we think about surgeon training progressing sort of going forward? What’s your capacity for number of surgeons you’d be able to train on a quarterly basis, particularly as we think about maybe the fourth quarter and into 2025?
Joe Gilliam: Well, if you look back, if you think about the training from a sales force standpoint in our various products, I think the peak that we achieved was now quite some time ago from a standpoint where we were doing 700 to 800 surgeons a year. I think one of the big differences with iDose that the majority of the surgeons that we’re training have already gone through angle based surgery. So from that standpoint, those early cases that are really designed to teach them or reteach them the nuance of ankle based surgery, you have a lot less of that. So I think that we’re going to set aggressive targets for the commercial organization to train as many doctors as possible certainly if we get in the fourth quarter going to 2025. And we’ll dial that in for you all as get into that phase and we start to really see what the sales force can achieve quarter in and quarter out.
Operator: Your next question will come from the line of Allen Gong with JPMorgan.
Allen Gong : Just one on iDose as well. You talked about how you’re working to get coverage, from Medicare and commercial plans. A question that I’ve been getting is just concerns around the co-pay in areas of Medicare and commercial where the out of pocket is not necessarily covered. How do you plan to address that in cases where you can’t provide some additional financial cushion, I suppose and where supplemental insurance isn’t as prevalent?
Tom Burns: Yes. Allen, something that we spend an awful lot of time obviously thinking about and assessing and analyzing in detail as a team well before we set the price and certainly launched iDose. I break it down this way, obviously within the Medicare fee for service world of which is significant obviously portion of the relevant lives here exist. The vast, vast majority of those patients actually have some degree of supplemental coverage. It can vary from a lot of different places, whether it’s supplemental from Medicaid or whether it’s from commercial plans or other supplemental coverage plans that they may have. So for the vast majority of those patients, you’ll have really little to no out of pocket. The second major bucket you alluded to is obviously within the commercial arena.
And for that, we’ll be approaching that similar to any drug launch or the vast majority of drug launches out there where we will have full co-pay assistance such that from that standpoint, patient economics will not be an impediment to the utilization of iDose in that payer arena. And the last frontier for us and quite frankly for most procedures and pharmaceuticals today will be Medicare advantage, where a larger percentage of those patients have a higher out of pocket, both in terms of the percentage as well as the overall maximum. And that’s something that is not unique to obviously iDose or Glaukos in that perspective. There are a decent percentage of those patients who do have no to low co-pay. And for those who have higher, you tend to see them get treated more in the later part of the year when they may have already exhausted their out of pocket maximums earlier in the year with whatever procedures might have arisen over the course of that year.
Operator: Our next question will come from the line of Joanne Wuensch with Citigroup.
Joanne Wuensch: I have two. The first one has to do with iStent infinite. I mean, that seems to be getting lost a little bit in the iDose focus. How is that doing and what percentage of the procedures today are in standalone procedures versus concomitant? And then I do have to ask about iDose, and you’ve been seeing street models and things like that. How are you feeling about full year contribution, for iDose? And I want to just make sure that expectations are iDose? And I want to just make sure that expectations are set accordingly.
Tom Burns: I think first, I appreciate the question, I think it’s been it does get lost a little bit in the shuffle of items yet it’s an essential part of what we’re doing every day right now in driving what we believe is sort of a shift in the standard of care towards interventional approaches and interventional glaucoma. To the heart of your question is, of course, it’s a little difficult to quantify with precision and we don’t have enough data to confidently say exactly how that breaks down between standalone and in combination with cataract. But I can confidently say it was a key growth driver in the quarter. And if you just look at it analytically, the reason why this is the reason why our Stint portfolio went from portfolio went from mid-single-digit growth in pretty much every quarter in 2023 to now mid-teens in the first quarter of 2024.
What changed there clearly was the fact that we started to establish professional fees that the APC assignment was reassigned to a level that the facilities aren’t losing money anymore. And that really enabled the surgeons to start doing what they would have loved to have been doing all along from a clinical perspective. So it was the key driver obviously to the first quarter as we had expected, but quite frankly it did even better than what we thought going into that first quarter. As it relates to iDose and the full year contribution, I don’t think we’ve gotten that granular around how that will play other than to continue to reiterate that it’s right now we’re in that early access phase, continue to be in that stage for the at least the first half.
And as you go into the third quarter and certainly the fourth quarter as the J-code turns on the J-code plus the ASP reimbursement, we would expect it to become a material driver of our results. When you look at what I said earlier around the seasonality that we expect and the shift towards the second half and the latter part. Clearly, the vast, vast majority of that is being driven by iDose and increasing utilization of that as we make our way through the year.
Operator: Your next question will come from the line of Margaret Kaczor with William Blair.
Margaret Kaczor: I’m going to pile on to infinite as well, because obviously it’s growing at a pretty rapid pace, so it seems like anyways. And I guess the comps are getting more difficult. And I know you’re a little maybe not wanting to focus on sequential growth. But I guess from a dollar perspective, can you give us any sense as to whether that infinite number sequentially is accelerating? Is it staying similar, et cetera? And then just a sense of penetration rate, either from broader account usage and existing accounts, but no one like Internet versus trying to get into new accounts?
Tom Burns: I think that from a performance standpoint, it’s certainly our expectation that infinite would continue to grow sequentially just based upon the organic efforts of our sales force around driving education, awareness and training of iStent infinite, in particular in the standalone setting. So I think it’s absolutely our expectation that will continue to be a growing driver of our overall business. To your point, we may have varying degrees in terms of how that translates from a year-over-year growth perspective just given comparable differences in 2023. But we absolutely expect it to be that. I think in terms of penetration, it’s still really early. I mean, you’ve heard us talk about the standalone opportunity measured in a couple of 100,000 procedures for iStent infinite for patients who fail medical surgical therapy.
And so just in translating even the great results we had in the first quarter, we’re still very early in the overall penetration paradigm of iStent infinite and where it can and we expect it to be utilized.
Margaret Kaczor: And I’ll squeeze in kind of the two both on iDose as well as just a follow-up on Internet. Because I think at our conference even last year, you guys have spoken to like to just your general enthusiasm with us. This is going to be a $50 million plus business over time, maybe even faster than iDose to get there. So I don’t know if you can speak I don’t know if you can speak to your confidence level now that both products have launched, around that commentary, around timing today versus last summer. And then on the on the iDose side, I’m not sure if you can give us any color around how the initial surgeons and clinicians are working iDose into their workflow. Are they focusing a day exclusively on iDose? Are these patients that have been waiting for a long time and how far out are these cases being booked?
Tom Burns: Well, I think, Margaret, it’s probably I’m just going to answer the one first. I think it’s probably a little bit premature to make too bold of a statement with respect to how they’re working it in, given where we’re at in that launch curve. We certainly do have those surgeons who are now working in wholesomely in the context of how they think about an interventional approach to the treatment of patients. And they all have their own algorithms, but we’re certainly seeing iDose TR in some of these thoughts become a prominent component of their algorithm. And it relates to I said infinite on the overall size of the market. I don’t think anything’s changed there. I don’t think we’ve changed our conviction. In fact, seeing the results that we’ve seen so far this year, it only probably increases the conviction around the ultimate use case of iStent infinite and that it should be a several $100 million product from a standalone perspective for us.
Again, just going back to the size of the market, you don’t have to change the paradigm around an interventionalist approach for iStent infinite to be utilized in those patients who failed medical surgical therapy. Those surgeons are already there. It’s about making sure that they’ve been trained and they have access and they’re appropriately thinking about it in the context of their own algorithms. But we have a lot of confidence in where that’s going to head over the course of time.
Operator: Your next question comes from the line of David Saxon with Needham.
David Saxon: Couple on iDose as well. So it sounds like each of the 15 docs did about seven or eight in the first two months, that iDose was commercial during the quarter. So how quickly did you see the first cohort do the second and third procedures and so on? Did they wait until they got reimbursed for the first and then do five or six more? Or was it more even over the two months?
Tom Burns: I think it’s a little early to do that. And I don’t think sometimes especially in the early days of launch to do that kind of the math, which I certainly respect around the seven or eight, you just see a wide variation where there are some surgeons who’ve done more than that, obviously, and there are others who have done one or two or three or four and then waiting for that reimbursement to come. Again, back to my earlier point, at this stage it has a lot more to do with their experience with miscellaneous codes both from a surgeon as well as a staff perspective. Then their understanding of how that will play out is driving the early adoption as much as anything else. I think over time, as that reimbursement confidence is established, you start shifting a lot more to the clinical conversation of when, where and how they’re deploying this. But right now, it’s coming down a lot to their experience with the miscellaneous code and waiting for that payment.
David Saxon : And then, you’ve talked in the past about the specialty pharmacy channel. So can you talk here about kind of what the process is to get that established and how long that might take? And then thoughts on how, if at all, that drive adoption further?
Tom Burns: Yes. So especially pharmacy channel is not new to us. Obviously, it’s an important part of our business on the Photrexa side, one in which we’re continuing to optimize each and every day. But it plays a very material role in the — I’ll call it distribution and channel strategy associated with Photrexa. Based upon that, the establishment of that from an iDose perspective is already there. We have all that ready, but you really don’t expect to start driving the utilization within that channel until you start to turn on your commercial policies and drive that non, call it Medicare business where the specialty pharmacy channel is most beneficial. And the second underlying layer of that obviously is that you’re always been cultivating the relationships as a specialty pharmacy provider with the various payers that are out there.
