Q1 2024 Glaukos Corp Earnings Call

Participants

Chris Lewis; VP of IR & Corporate Affairs; Glaukos Corporation

Thomas Burns; Chairman of the Board, Chief Executive Officer; Glaukos Corp

Joseph Gilliam; President, Chief Operating Officer; Glaukos Corp

Alex Thurman; Chief Financial Officer, Senior Vice President; Glaukos Corp

Tom Stephan; Analyst; Stifel Financial Corp.

Ryan Zimmerman; Analyst; BTIG, LLC

Larry Biegelsen; Analyst; Wells Fargo Securities, LLC

Matt O'Brien; Analyst; Piper Sandler & Co.

George Sellers; Analyst; Stephens Inc.

Alan Gong; Analyst; JPMorgan Chase & Co.

Joanne Wuensch; Analyst; Citigroup Inc.

Margaret Kaczor; Analyst; William Blair & Company

David Saxon; Analyst; Needham & Company, LLC

Sam Brodovsky; Analyst; Truist Securities

Steve Lichtman; Analyst; Oppenheimer & Co.

Michael Sarcone; Analyst; Jefferies LLC

Presentation

Operator

Welcome to Glaukos Corporation's First Quarter 2024 financial results conference call. Copies of the Company's press release and quarterly summary documents both issued after the market close today are available at www.glaukos.com. All lines have been placed on mute to prevent any background noise. After the speakers' remarks, there will be a question and answer session if you would like to ask a question, simply press star followed by the number one on your telephone keypad. You withdraw your question, press star one. 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.

Chris Lewis

Thank you and good afternoon. Joining me today our 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 & Filings Quarterly Results section titled Quarterly summary document is designed to provide the investment community with a summarized and easily accessible reference document that details and impacts associated with the quarter as seen in 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 an 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, 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 also discuss certain non-GAAP financial measures by any 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 on the Investor Relations section of our website for a reconciliation of these measures to their most directly comparable GAAP financial measure.
With that, I will turn the call over to Glaukos Chairman and CEO, Tom Burns.

Thomas Burns

Okay. Thanks, Chris. Good afternoon and thanks to all for joining us today. Today, Glaukos reported record first quarter consolidated net sales of $85.6 million, up 16% versus the year ago quarter. As a result of our strong start to the year, we are increasing our full year 2024 net sales guidance range to $357 million to $365 million versus $350 million to $360 million. Previously, these record results were broad-based with 20% year-over-year growth achieved in both our U.S. and international glaucoma franchises are we continuing to accelerate efforts to expand access to interventional glaucoma tools for the benefit of physicians and patients are told to advance and improve care by driving earlier intervention continues to build momentum as we lead and work closely with surgeons about theaters globally to organically drive this broader evolution in the standard of care. These efforts were on full display at the AGS conference in late February and more recently at the ASCRS meeting last month for the interest and excitement levels for interventional glaucoma and our technologies were comparable within our glaucoma franchise, we delivered first quarter sales of [42 million] on strong year-over-year growth of 20%, driven by ICE and infinite and our overall debt portfolio, market receptivity and adoption of ICE and infinite remains strong as we continue to pioneer and lead the international glaucoma paradigm shift. In parallel, we continue to advance key market access initiatives to support consistent and dependable professional e-payment with five of the seven MAX now including CPT code boasts several 1T by the latest schedules. During the first quarter, we also commenced the initial phases of our controlled launch plan for Eidos TR, our revolutionary micro invasive injectable therapy designed to lower intraocular pressure in patients with open-angle glaucoma or ocular hypertension, high-dose TR as of the first of its kind intracameral procedural pharmaceutical designed to deliver glaucoma drug therapy for up to three years. I cannot be more pleased with how the early stages of this launch have got our initial target rate of 15 surgeons all successfully completed our high-dose initial high-dose TR procedures during the first quarter and the early feedback and outcomes have been very positive. As a reminder, these early access surgeons provide valuable insight to our training and field teams that helps to optimize training and skills transfer to our sales force and surgical community, supporting our expanded training and broader launch efforts. Over the course of 2024.
In addition to training, a key element to the stage gating of our Eidos Tiara commercial launch is market access, where there have been several recent positive reimbursement developments designed to support full some coverage and payment by the ISTR. procedural pharmaceutical over time. So first, CMS assigned a unique permanent J code for Eidos TRJ. 7355 set to become effective on July 1, 2024. This new J-code was effective, I suspect, is expected to increase patient access here in the United States and should provide more streamlined consistent and dependable coverage and payment for IDESTR. as we advance and ultimately accelerate our initial commercial launch activities. Second, CMS has signed the CPT. codes that are designed to be used to cover the procedural component of Eidos TRO. six six zero TE. and O. six six one T. two ambulatory payment classification, or APC 5492 effective April 1, 2024. This translates into a national average facility fee of nearly $3,900 in the House HLPPD. setting and more than $2,000 in the ASC setting.
Third, we have participated in several initial education needs with MACs as part of our efforts to secure professional fee coverage and payment over the course of 2024.
And fourth, we successfully entered into the Medicaid drug rebate program or MDRP.
And finally, fifth, we have successfully commenced early initiatives to secure coverage for commercial and Medicare Advantage plans efforts that we plan to accelerate in the second half of 2024 after the J-code is effective.
So in summary, the response we've received from surgeons and the broader apartment community since FDA approval and the more recent initial commercial launch activities has been overwhelmingly positive and reaffirms our view that with the launch of ISTR., we are pioneering a branded category to procedural pharmaceuticals that has the potential to reshape glaucoma management as we know it today. We are excited to now be building the strong foundation that bring this transformative technology to market and expand the treatment alternatives for patients suffering with glaucoma and ocular hypertension.
Moving on, our international glaucoma franchise delivered record sales of $25.2 million on year-over-year growth of 20% on a reported basis and 21% on a constant currency basis. This strong growth was once again broad-based as we continue to scale our international infrastructure and execute our plans to drive things forward as the standard of care in each region and every major market in the world. We remain in the early stages of expanding our IG initiatives globally ahead of what we hope will be supported by a healthy cadence of new product approvals and expanding market access in the years to come.
And finally, our corneal health franchise delivered sales of $18.4 million on 4% year over year growth, including Photrexa sales of $15.1 million on a year over year growth of 7%. These first quarter results do include, in particular the impact of our entry as a company into MDRP. These dynamics were anticipated and will continue to impact Photrexa realized revenues going forward shifting gears, we continue to prudently invest in and successfully advance our 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. This includes at the onset, our next-generation corneal cross-linking therapy, for which we continue to progress towards trial completion in the second Phase three pivotal trial and remain on track for data readout in the second half of this year, supporting our targeted NDA submission by the end of 2024. We continue to make inroads and progress in several important clinical trials, including one, a PMA pivotal trial priced an incident in mild-to-moderate glaucoma patients to our Phase IIa study for Irish travel costs with an initial data readout expected later this year, three Phase two trials for our high link third generation therapy and first in human clinical development program for GLK., all one, our intravitreal multi-kinase inhibitor rental program in wet AMD patients. We also remain on track to commence and commence a Phase three study for high-dose TREX., our next-generation high-dose therapy by the end of 2024. Beyond these clinical activities, our development teams continue to pursue potential game-changing early-stage programs across the areas of glaucoma, retina and rare disease.
So in conclusion, I'm pleased with the strong start into the year. Given our team's solid execution, I'd like to thank the nearly 1,000 Glaukos employees who remain dedicated to the work and advancing our strategic plans. We look forward to continuing to sustain and build upon the growing momentum momentum in our business over the coming quarters and years. Our foundation is strong and our teams are energized as we are ideally positioned to continue to transform envision for the benefits of patients worldwide.
So with that, I'll open the call for questions. Operator?

Question and Answer Session

Operator

At a time as a reminder to ask a question, press star one on your telephone keypad. Our first question will come from the line of Tom Stephan, Stifel. Please go ahead.

Tom Stephan

Great. Hey, guys, thanks for the questions. And maybe I'll start on the guide. Can you maybe talk about what the changes are to the construct of the full year revenue outlook? We can begin there? And then is there any more color or I guess parameters you'd be willing to provide on what's baked in for Altace?

Joseph Gilliam

Sure, Tom, it's Joe. Thanks for the questions. And I'll start off with the guidance. Obviously, we had a stronger than expected start to the year, and we've been able to raise our full-year guidance accordingly here.
Just a couple of months after setting and for the year, I'll call it a couple of key considerations. I think that are worth highlighting and then kind of hopefully draw some clues in terms of expectations by the franchise. First done. It obviously is very early in Eidos launch with the vast majority of the contribution expected the latter part of the year. That hasn't changed everything that we've been doing so far in the first quarter is on track and on target, and we can I'm sure talk about that more later.
Some of the stent growth that we saw in the first quarter, which was which was very strong from a year-over-year basis, is partially driven by timing of the embedded launch activities last year, which really accelerated in the second quarter. So I think as we move into the second and third quarters, the comp from a fit standpoint get start to get a little bit more difficult. And third, obviously, we all know that FX rates and the strengthening dollar have been moving against many of us from a US reporting standpoint. So we see an incremental 200 basis points of growth headwind on international side as we move forward throughout the year based on the spot rates as they exist today.
And then lastly, as Tom mentioned in the prepared remarks, we do expect the MDRP. entry related headwinds to persist for our corneal health franchise throughout the year. So you put all that together. I think we're landing in place where we our expectations for the cornea franchise are low to mid single digit growth for the year.
The international glaucoma business, we pick up a little bit, I think expectations there should be low to mid double digit percentage are [10s] growth for the year and that'll land you somewhere for the U.S. glaucoma business in that high 10s to maybe at the top end, 20% type growth year over year. So hopefully that gives you a sense of kind of the drivers of where we're at.
For your second question around Eidos TR. I think at this point, we're obviously some quite early. We were very pleased to see that in mid February, we told you we were going. And so in the second half of the quarter, we were able to get kicked off with the Early Access phase or Eidos launch. And as Tom mentioned, I'm really pleased to see our initial 15 surgeons to be able to complete their case cases in Q1 in correlation with our sales and training and market access teams. And that's how we'll continue to methodically launch in slowly expand in Q2, ahead of obviously the J code being established in Q3 of the publication in Q4. Will we start to expect a meaningful acceleration in the autos related activities and volumes.

Tom Stephan

That's great color. Thanks, Joe.
And then maybe switching to the pipeline from Tom, you alluded to this a bit, but we did see in your proxy, but the company is developing high-dose Trio, which appears might be in office version of the implant. If you're willing to share. Can you elaborate a bit of product, maybe the key details sort of the portfolio fit, I guess and then any time lines or my stones? Thanks.

Thomas Burns

Yeah, we haven't addressed that time. And so I think it's inevitable as we look at the evolution of the pipeline, then we'll continue to figure out ways and develop ways to have an even more minimally invasive and test our procedure.
So having said that, I think it's incumbent upon us to develop a product that will be able to be even more micro basis than the current high-dose design and have an applicator that we'll be able to to really be able to put EIDI. dose product through an incision size, that's that's going to be able to be in the range of a 1.2 millimeter to 1 millimeter incision, which really gives us then the opportunity to create a self sealing construct or temporal clear corneal incision. And that will be important, particularly as surgeons move to in-office procedures, which we know that they will do it, which is a compelling part of our strategic plan over the course of the planning period. So we are in the process of developing an applicator that will accomplish and achieve those goals. I would say the timing we'd be looking for would be probably in late 2025 for potential introduction. And I think that will then be timely with the effect of how we'll be moving forward to give surgeons the opportunity to be able to exercise on the site of service in office as well as the ASC.

Tom Stephan

Got it. That's helpful. Thanks again.

Operator

Your next question comes from the line of Ryan Zimmerman with BTIG. Please go ahead.

Ryan Zimmerman

Hey, good afternoon. Congrats on all the progress I'm going to follow up on Tom's questions that I'm sure a lot of people the asthma high-dose, but you gave us a little detail here on 15 surgeons kind of completing initial high-dose TR cases. Now many of us have in our diligence in this, and it would seem as though there may be more surgeons out there or at least there's a lot of excitement out there. Just to confirm, have you put high-dose in the hands of more than 15, number one? And then two, kind of how do you think about expanding is that beyond that initial wave of the 15 in the second quarter in total, kind of that J-codes are effective? And are you gaining adoption in any way or kind of holding demand before that J-code is effective?

Joseph Gilliam

Yes. Sure. Thanks, Ryan. And I think the the the answer to the number of surgeons who had asked us and I think a little bit you're reacting to the overall number one, the overall figures, the Atom for ISTR. and some of the pent-up demand for folks to get trained and get going with it over the course of the year. But the direct answer is yes. Now that we're sitting here on May first, of course, we continue to expand. We're past that the 15 number from a sort of training perspective was as of the end of the first quarter. So you would expect us to continue to be slowly expanding that and providing more access to folks at the same time span we're going to do so methodically, as we talked about from the outset, I think even back to the items, call it December the way we will launch this product, is those early access physicians expanding that very slowly and methodically over the course of the second quarter and then really starting to open that more broadly as we get into the second half of the year with the J-code being established at the same time. And in parallel, we are working with these accounts. And so simply because the surgeon meeting that hasn't completed. The first case does not mean that they're not in the funnel or if you're doing channel checks expressing their enthusiasm because they're being trained their back office, administrative staff are being trained. And so we're continuing to make progress really on all those fronts as we need as we move move forward into what we think will be a pretty exciting, certainly second half and most notably fourth quarter for this year, latest.

Ryan Zimmerman

Okay, very helpful. And then kind of dovetailing off that, Joe, I mean, if you are in those accounts. I'm curious what impact or pull through or you're seeing as a result of the Eidos efforts on the base business and if you could kind of tie it to this infinite growth, particularly in the US. I mean, I would venture to guess that the market is not growing anywhere near 20%. And so are you taking share are you is the market growing faster now because you are spending more time on accounts, maybe to elaborate on kind of the core mix business and the resulting impact from your efforts on items?

Joseph Gilliam

Yes, I think it's a great question. So I'll provide a little bit of color, I think will help you triangulate around the breakdown of the results for the first quarter for the U.S. glaucoma business, we did see our overall U.S. stent portfolio, including ice and infinite, grow in the mid 10s on a year-over-year basis. So the majority of what you're seeing now, obviously, we did have a CR and some of the early launch activity, but the majority of the growth that you're seeing, the tune of mid 10s growth is coming from our stent portfolio. I think it's, of course, very hard to dissect that down to individual percentage breakdowns. But I do think it's a little bit of all of those things that you mentioned, Ryan, I think that we are growing the market because of And as Tom mentioned, we put a lot of muscle and effort into the interventional glaucoma paradigm shift that that's not something new. We've been working on that hard over the course of the last 15 to 18 months, in particular that I think you're starting to see some of the benefit of that in terms of growing the overall market, certainly faster than would be still restricted the combination cataract setting. But at the same time, I also do think we're taking a little bit of market share. And I think the fact that we're in there with multiple new exciting technologies that help expand the portfolio of alternatives for the surgeons you can't help, but benefit a little bit from that in the context of a halo, obviously associated with overall portfolio. And so I think that that is playing out a little bit as we make our way through the year so far.

Ryan Zimmerman

Thank you.

Operator

Your next question comes from the line of Larry Biegelsen with Wells Fargo. Please go ahead.

Larry Biegelsen

Good afternoon. Thanks for taking the question and congratulations on a really strong quarter here. So Joe, you raised the guidance at the midpoint by, I think the amount of the beat. Why not more and the Q2 to Q4 growth implied or implied growth is actually below the Q1 growth, I think, at the midpoint.
And just lastly on the assortment, how should we think about Q2, are you comfortable with consensus of, call it $88 million?

Joseph Gilliam

Yes, I think in the kind of outright ticket order, which as you asked it, but the context of why not more than the beat will hit over the course of the two months. I'm not so sure since our original guidance that things have changed markedly versus expectations and what we saw coming into the year. We've executed on everything we expected to and done a little bit better than that. And so we wanted to make sure that that was reflected in the raised guidance. But when you think about getting ahead of that, so much of that obviously is driven by expectations around Eidos in particular. And as I've said, and we've said for some time now that's for the most part, a second half phenomenon that we expect to play out. So I'm not sure sitting here today, we would make a significant change our expectations around Eidos and what it will do in the second half. But we certainly continue to execute against realizing that opportunity at that point in time.
You think about Q2 I alluded this a little bit in the question around the guidance for our first quarter did benefit a bit from two things. One, on the international side, currency was a little bit more favorable than it's going to be going forward. We see an incremental 200 basis points or 2% of headwind on that international growth number as we entered the second quarter than what we experienced in the first given the strengthening of the dollar. And in second, we really more fulsomely launched ice at Infinity in the second quarter of last year. So from a year-over-year comp standpoint, it gets a little bit more challenging as we enter the second quarter and beyond than it was in the first from a from a growth standpoint. So I think you put those things together and you you'll see why and where we landed.
The last thing I'll say on that is from a seasonality standpoint, when you kind of think about the overall guidance?
We as you know, we expected our typical seasonality patterns have been disrupted this year by growing nice and infinite standalone. And of course, high-dose utilizing utilization the second half and the net effect of that is obviously the shift a bit more of the contribution of the year to the second half and in particular the fourth quarter. And if I were trying to put percentages around that, I might do something like the following 23.4% in Q1 '24, 25% in Q2 and Q3 and 26% to 28% of the year in Q4. I think if you follow that, you'll get to a pretty good place in the context of the seasonality expectations that we have for 2024.

Larry Biegelsen

That's helpful. Joe, just a follow up on the Eidos ramp. I mean, how should we think about the ramp you know and what's going to cause that inflection in Q4? Is it is it the J code coming into effect in June July first until we'll see an inflection in Q3?
It sounds like the contribution in Q1 was relatively small. How do you see what's going to drive the adoption through the year? Thanks.

Joseph Gilliam

Yes, I mean, the focus from obviously our expectations I think would be that the contribution in the first quarter was relatively small and we launched it in mid February and gave early access. And we're on schedule hall that I think will continue to expand that over the course of Q2. But to the heart of your question there really to fund significant unlocking events, if you will, from a from an adoption perspective, the first happened on July first. When you have the J-code come into place, there's obviously a lag effect there in terms of procedures being scheduled and execution on towards that J code. But then as you get into the fourth quarter and the ASP. is also publish at that point, you have a much more, I'll call it, automated payment system from a Medicare standpoint, when you have the established J-code and they publish a SP., it really enables a much more normalized process for reimbursement at the account level and we expect that to be pretty important in the unlocking, obviously, of surgeons really be able to run and do items and all the patients that they think are appropriate for the technology.

Larry Biegelsen

Thanks a lot.

Operator

Your next question will come from the line of Matt O'Brien with Piper Sandler. Please go ahead.

Matt O'Brien

Afternoon. Thanks for taking the questions. Maybe just to follow up a little bit on Larry's question there on the performance of Eidos in Q1. And yes, you're going to get to those questions on the call. But and if I look at if I think about the base business maybe growing somewhere in the mid 10s. If I if I back that out, I'm looking at somewhere around something like a seven figure performance in the first quarter, as said another way over $1 million. Is that about the right number and that's just on 15 docs, right. Just kind of trial, are you trying to figure out the J-code. Is that in the ballpark?

Joseph Gilliam

Well, I'm not going to get too specific in the endorsing any one number, but obviously you've got the overall growth of the U.S. glaucoma franchise, and you've got that the stent portfolio grew in the mid 10s from a year-over-year standpoint. So you, as you've done, can do the implied math on that I'll just reiterate what we said. I mean, at the end of the day, there were 15 implanting surgeons in the first quarter. They had about a half of a quarter to do those procedures and based on the timing of our launch. And it was encouraging to see both the most importantly, the enthusiasm for the outcomes for those patients after they after they've done their initial implantations of items and they managed to provide is exactly what we need, the kind of pearls and information that help us dial in our training and ultimately establish confidence with our sales force as they execute on a growing basis over the course of the next several quarters.

Matt O'Brien

Got it. And then the follow-up is just on the profitability side, I think which I think you've said historically, when you had you had lunch profitability of the gross margin was good this quarter. Should we expect that to dip a little bit as those ramps and then improve meaningfully going forward are nicely going forward. And then the spend also was much better than we were expecting just given all the activities around dose here in the quarter. So can we start to see profitability start to ramp pretty meaningfully over the maybe 18 months? Thanks.

Alex Thurman

And that's Alex. I'll go ahead and take those questions. So we'll start with gross margin. Yes, we were pleased with the 83% in the quarter for sure. But as we mentioned the last call, and I'll say it again, as you know, when you launch a new product, it's bound to see some inefficiencies in the operations start to ramp up that product and the manufacturing and the all the costs that are associated with that. So what we would tell you or what I would guide you to is some some level of range. We've always said [83%] for we hope to continue to play in that range this year. But there should be and could be some volatility as we as we go through the next couple of quarters. And it just gets ramped up. And then we think about the margin being accretive over time with those for sure. And we look forward to that accretion, seen some of that next year on the operating side, you're right, we were pleased with the [92], if I back out the IPR&D charge of $11.7 million. So that was nice. But one thing I'll just say on the expense side is that in Q. one of last year and the R&D spend was much higher than normal because we had all of the Eidos pre-NDA activities that were happening as well as a large producer fee payment that needed to be made. And so that kind of explains a little bit of the slowdown if you're comparing on a year-over-year basis.

Matt O'Brien

Got it. Thank you.

Operator

Your next question comes from the line of George Sellers with Stephens. Please go ahead.

George Sellers

Hey, thanks for taking the questions. Maybe sticking with the Eidos theme, could you just provide some additional color on maybe what you're seeing or believe 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 makes procedure. And then also what stage of the the disease progression these patients who are receiving high dose or?

Joseph Gilliam

Hey, George, it's Joe. I think at this point when you're early in a product launch like this, you tried 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 said in the past, the primary goal there is for clean stand-alone utilization of items. Now having said that, have we seen surgeons for clinical reasons do it either in combination with cataract surgery or in combination with ICE and incident. 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 on sticking very close to the playbook that we prescribe as we drive this forward. And we'll continue to see surgeons expand the use case of Vitis go forward utilization itself and the trends of surgery within very different from account to account those accounts who have experience in billing miscellaneous codes. We've seen them really start to utilize items more fulsomely for those with a little less experience they will start will drive will do a handful and wait for the payments to pull through before they GreenLight that broader adoption.

George Sellers

Okay. That's really helpful color. And then maybe go 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 quarterly basis, particularly as we think about maybe the fourth quarter and into 2025?

Joseph 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 spend standpoint where we were doing seven, 800 surgeons a year. I think one of the big differences with high-dose that the majority of the surgeons that we're training have already gone through annual base surgery. And so from that standpoint, on those early cases that are really designed to teach them or reach that the nuance of angle 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 is certainly begin the fourth quarter going to 2025, but it will dial that in for you all as we get into that phase. And we start to really see one the sales force continued quarter in and quarter out.

George Sellers

Okay, great. I'll leave it there, and thank you all again for the time.

Joseph Gilliam

Sure.

Operator

And your next question will come from the line of Alan Gong with JPMorgan.
Please go ahead.

Alan Gong

Thanks for the question. Just one on Eidos as well. You talked about how you're working to get coverage from Medicare and commercial plans. Question that I've been getting is just concerns around the co-pay and areas of Medicare and commercial, where you know the out of pocket and not necessarily covered. How do you plan to address that in cases, where you can provide some additional financial and on cushion as opposed and where supplemental insurance isn't as prevalent?

Joseph Gilliam

Yes, Alan, something and we spent an awful lot of time, obviously, thinking about in assessing and analyzing in detail as a team of well before we set the price and certainly launched Eidos, I break it down this way. Obviously, within the Medicare fee for service world, which is significant. Obviously, portion of the relevant lines 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 allude to is obviously within the commercial arena. And for that, we'll be approaching it 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 Eidos in that 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 Eidos will work well because that perspective, there are a decent percentage of those patients who do have a note to low co-pay. And 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 some of their their out-of-pocket maximums earlier in the year with whatever procedures that might have arisen, of course, that year.

Operator

Our next question will come from the line of Joanne Wuensch with Citigroup. Please go ahead.

Joanne Wuensch

Good evening, and thank you for taking the questions I have to unfortunately has to do with I send Internet. I mean that seems to be getting lost a little bit the Eidos 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 that Eidos and you've been seeing street models and things like that. How are you feeling about full year contribution for Eidos? And I want to just make sure that expectations are set accordingly.
Thank you.

Joseph Gilliam

Thanks Joanne, I think first, I appreciate the question I've been invited, you don't it doesn't get lost a little bit in the shuffle of Eidos and yet it's an essential part of what we're doing every day right now in driving and what we believe is sort of a shift in the standard of care towards interventional approaches and interventional glaucoma. Still part of your question is, of course, it's a little difficult to quantify with precision precision. And we don't have enough data to confidently, say exactly how that breaks down between stand-alone and companies of 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 you know this is the reason why our stent portfolio went from mid-single digit growth in pretty much every quarter in 2023 to now mid 10s 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 up to a level that the facilities are losing money anymore. And that really enables surgeons to start doing what they would have loved to been doing all along from a from a clinical perspective. And so it was the key driver, obviously, to the first quarter as we as we go I'd expected, but quite frankly, it did even better than what we thought going into that into that first quarter.
As it relates to Eidos in the full year contribution on the I don't think we've gotten that granular around how that will play out 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 when you look at what I said earlier around the seasonality that we expect the shift towards the second half and the latter part, clearly, the vast, vast majority of that is being driven by items and increasing utilization of that as we make our way through the year.

Joanne Wuensch

Thank you very much.

Operator

Your next question will come from the line of Margaret Kaczor with William Blair. Please go ahead.

Margaret Kaczor

Hey, good afternoon folks, thanks for taking the questions that I'm going to pile on on to infinity as well, because obviously, it's growing at a pretty rapid pace. 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 incident number sequentially is accelerating, is it staying similar, et cetera? And then you have just a sense of penetration rate either from broader account usage in existing accounts. But, you know, unlike Internet versus I'm trying to get into new accounts.

Joseph Gilliam

Yes, Margaret, I think that from a performance standpoint, it's certainly our expectation that Infinity 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 some it's absolutely our expectation that 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 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 stand-alone opportunity measured in a couple of hundred thousand procedures for ICE and infinite for patients who failed medical surgical therapy. And so just in translating, even though the great results we had in the first quarter. We're still very early in the overall penetration penetration, paradigm of iStent infinite and where it can, and we expect it to be utilized.

Margaret Kaczor

Okay. And I'll squeeze in kind of the two both on Eidos as well as just a follow-up on taxes. I think at our conference season last year, you guys had spoken to like just your general enthusiasm that this is going to be a [$50 million], $100 million dollars plus business over time, maybe even faster than Eidos can get there. So I don't know if you can speak to your confidence level now that both products have launched around that commentary around planning today versus last summer. And then on the auto side of it, I'm not sure if you can give us any color around how the initial surgeons and clinicians are working I dose into their workflow. Are they focusing exclusively on? I don't feel are these patients that have been waiting for a long time and how far out are these cases being booked?
Thanks, guys.

Joseph Gilliam

What I think, Margaret, it's probably I'm going to answer the last 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 a given given where we're at in that launch curve. We certainly do have those surgeons who we are now working in fulsomely 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 Eidos PR in some of these thoughts become a prominent component of their algorithm. And we cited infinite on the overall size 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 device and infinite and that it should be a several hundred million dollar product and the standalone perspective for us, again, just going back to the size of the market, you don't have to change the paradigm around an interventional approach, price and intended to be utilized in those patients who fail the 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. Please go ahead.

David Saxon

Great. Good afternoon. Thanks for taking my questions. On a couple on Eidos as well. So it sounds like each of the 15 docs did about seven or eight in the first two months and I guess with 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 from the first and then do five or six more? Or was it more even over that two months?

Joseph Gilliam

thanks, David. I think it's a little early to do that. And I don't think, you know, sometimes especially in the early days of launch, is that kind of the math, which I certainly respect around the seven or eight, you just see wide variation where there are some surgeons who've done and more than that, obviously. And there are others who have done one or two or three or four and then wait 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 stat perspective than their understanding of how that will play out is driving the early adoption as much as anything else. I think over time is 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 for right now, it's coming down a lot to their experience within miscellaneous code and waiting for that payment.

David Saxon

Okay. Got it. And then I'm you've talked in the past about the specialty pharmacy channel. So can you talk here about kind of what the processes to get that established and how long that might might take? And then your thoughts on how, if at all that, that drives adoption further?

Joseph Gilliam

Yes. So the specialty pharmacy channel is not new to us. Obviously, it's an important part of our business on the Texas side, one in which we're continuing to optimize each and every day. But it plays a very material role in the ongoing distribution and channel strategy associated with Photrexa. Based upon that, the establishment of that from from a from an IT 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 called Medicare business where the specialty pharmacy channel is most beneficial. And a second underlying layer of that, obviously, is that you're always been cultivating the relationships and as the specialty pharmacy provider with the various payers that are out there. So that process will be ongoing over the course of many years. You're trying to optimize the coverage within their channels to benefit those commercial patients who who who will rely upon it, but we're ready to go. It's much more about us, really unlocking or releasing on the commercial side of our of our high-dose business before we start to meaningfully make a change, especially pharmacy side.

Operator

Your next question will come from the line of Sam Brodovsky with Truist Securities. Please go ahead.

Sam Brodovsky

Hey, guys. Thanks for taking the questions guys. Two quick ones on Eidos and then I'll speak in an international one as well. First, just any update or any color you can provide on incremental data on let me make it a replacement label or though how those conversations with the FDA are evolving?

Thomas Burns

Yes, Sam, thanks for the question. Thanks for allowing me to engage. Have questions on Hydro's commercial? Yes, as we talked about, we have, I believe, prepared a really compelling proposal to submit to the FDA. We waited. As you know, there's been a change in the guard at the FDA. And so that dust is still settling. So we will be proposing the movement towards re administration and really in the coming days, we're hopeful to be able to get a positive response, but we're not counting on it. And I will tell you, as I've said before, one of the things that investors and analysts should be reassured by is that we have T regs which were on track for beginning that clinical trial by the end of the year. And when you do any kind of chronology of when our expectation is to have that commercially available, as we've talked about before, best case would be at the end of 2017 into '28. And so any patient that is undergoing a nice than implantation typically are invariably by the end of this year or early into 2025. We believe that the TREX. will become a compelling offering for the administration for those patients.

Sam Brodovsky

Great. That's helpful. And then also, is there going to be any constraints as you as you roll out to more doctors, any constraints we should be considering in terms of how much they can adopt over the coming months before for the JV, whether that be supply or otherwise?

Joseph Gilliam

Well, I think that is the reason because I think the way you asked that question in the context of the second quarter ahead of the J-code, I think it's honestly more of the same as we experienced in the second half of the morning, you'll see part of the second half of the first quarter. You're going to see some who are more confident and willing to adopt based on the clinical flow of their practice and obviously focused on the Medicare patient population. And you'll see others who will start and do some trying and ultimately wait for payment to the data. I don't expect there to be a meaningful inflection in the context the second quarter as it relates to items other than the fact that we'll continue to. So we expand access to those surgeons.
Sam and I'll leave it.

Operator

Your next question will come from the line of Anthony Petrone with Mizuho. Please go ahead.

Hey, guys. As Dmitry Joe on for Anthony, and congrats again on a great quarter. And so on your summary, you have ads initial educational meetings with the MACs as part of your efforts to secure professional fee coverage can you give us any updates from these talks? Do you have better insight and the timing of when these professional fee coverage will come through? And could they come all at once from the MAX will be staggered. Have a quick?

Joseph Gilliam

Yes, yes, Dmitry, I think this is ordinary course activities. We do anytime we launch new products. There's an education process is to make sure those MACs who are open to being educated on it on a new product like Eidos, they understand what it is and the procedure associated with the drug and so we've been executing on those as an ordinary course.
If you look back at the history of Glaukos, we've launched products, professional fees tend to take somewhere between six to nine months on average to start being at least more consistent in what they're being paid and ultimately then be put on fee schedules and they rarely happen all at once. They tend to happen on whatever schedule and time line. The max themselves individually are on our SIP being one one fell swoop across multiple MACs at a single point in time.

Okay. And quickly on gross margin. I know you came in a bit lower than expectations, Tom, and I know that's kind of due to the launch and you just see that. Do you see it stepping down next quarter or we see step up next quarter and kind of through the rest of the year?

Alex Thurman

And Dmitry, it's Alex. I would say TBD, right. We would just take, I'm kind of guiding that you should keep in mind a range of maybe between 80 to 84 over the course of the year because of the volatility or potential volatilities rollout, Itis. And so but we again of curve that we are confident in the accretive nature of Itis the gross margin over time, and we should start to see that more fulsomely as we exit this year and into next year.

Operator

Your next question will come from the line of Steve Lichtman with Oppenheimer & Co. Please go ahead.

Steve Lichtman

Thank you. Even guys. I wanted to ask about the core U.S. glaucoma business in markets. One of the things you highlighted in your summary is the potential volatility from and all of the MAC movement late at the latter part of 2023. Are you still seeing some aftershocks from that one way or the other? And also, if you could talk about what your expectations are looking forward? Are you hearing anything with regard with what might be next?
Excuse me on the macro front?

Joseph Gilliam

Yes, I think it's been relatively quiet in the context of the impact as there's probably a modest benefit to the stent side of our business. And some and surgeons or practices have reevaluated the tools that are being deployed and based upon the objective data that sits behind those tools. But I think it's a much smaller, negligible impact to the quarter versus as we've spent a lot of time here talking about the growing stand-alone utilization. For example, as we go forward, it's status quo for now on the Mac next steps. And the timing remains, I'm unclear. But as we've said before, we do expect to hear from them again. And that stance is really unchanged. And so as always, has been the case. Historically, we'll continue to support the right of the physicians to make critical decisions on behalf of their of their patients, if and when we see something from probably max.

Steve Lichtman

And Joe, just quickly on OpEx, should we still target about 10% growth year over year this year?

Alex Thurman

Hey, Steve, this is Alex, I'll take that one and thanks for the question. The answer is yes, I think the easiest way to think about it is from that over the next three quarters, I think of some kind of reasonable sequential increases over time that you landed the year at about a 10% growth in OpEx compared to the base in 2023, which was three 60, excluding IPR&D.

Operator

Our final question will come from the line of Michael -- Our final question will come from the line of Michael Sarcone with Jefferies. Please go ahead.

Michael Sarcone

Good afternoon and thanks for squeezing me in here from just the of another follow up on. I know it's, you know, going back through the first few years of the initial Ispat launch. I know you talked about you had a year or two where you added 700 new reps trained. You also often talked about, I guess in 2015, you know, the average rep training three surgeons per quarter. If you think about it kind of along those metrics, do you expect that the average rep today could train more surgeons than that, given that a lot of these surgeons are already trained and open with open-angle procedures? Or would it be something less than that because maybe they have more products in the bag to sell. Just wanted to get your thoughts on how you're thinking about that metric.

Joseph Gilliam

Well, I think you've you largely framed it the right way. And so that's why I'm a little bit hesitant to get too specific on the pace of that training, the I'll call it. The tailwind from a comparable standpoint is that, as you alluded to, we're not training the majority of the surgeons on angle based surgery. So from that standpoint, some of the harder elements of that training, we don't spend as much time on the offset to that is exactly what you said in that. We're not just simply launching a single product here. In the case of Eidos. We have a portfolio. There's a lot of activity around ice and infinite. And so I think we'll have to feel our way through as the reps start hitting their full stride in terms of Eidos training and onboarding as we kind of exit this year and go into next year. And we'll provide a little bit more context to that as we refine our own expectations.

Michael Sarcone

Understood, thanks. And just one quick one. You talked about you're commencing early initiatives to secure commercial coverage for Eidos. You can give us a download on any types of conversations you're having in the early days with commercial payers and what the feedback and or receptivity is?

Joseph Gilliam

Yes, those efforts are really just beginning on that. But there are a lot of conversations going on. In fact, there's actually a fair number of policies that have already been issued out there, even though we're not commercially trying to drive that side of coverage has started to turn on in a variety of the commercial payer and other settings around that. I think to date, what you've seen from those policies is exactly what we'd expect. And quite frankly, not all that dissimilar than if you look at the coverage policies that are out there for derisks us today, of which there are there are plenty. So in terms of the interventional procedural pharmaceutical approaches. I think the payer community thus far has been following the playbook that they establish with Teresa as they think about their coverage for fried OCR.

Operator

I will now turn the call back over to the company for any closing remarks.

Thomas Burns

Okay. I want to thank all of you for your time and attention today and continue to thank you for your continued interest and support of Glaukos. And with that, goodbye.

Operator

That will conclude today's call. Thank you all for joining. You may now disconnect.