My name is Steve Lichtman. I'm the medical technology analyst here at William Blair, who covers our next presenter, Glaukos Corporation. Before we kick off the presentation, I am required to inform you that for a complete list of research disclosures or potential conflicts of interest, please visit our website at williamblair.com. With that, we're very happy to have with us today Alex Thurman, Senior VP and CFO, and Chris Lewis, VP and head of Investor Relations. After the presentation here, we'll have a breakout in the Richardson room. With that, I'm happy to turn the mic over to Alex. Thanks.
Thank you, Steve, thank you, William Blair, for allowing us to be here today to talk to you all. Thank you all for coming, spending your lunch hour with us, so we can talk a little bit about Glaukos and let you know kind of what's going on. We'll start. I'm going to have Chris read this for us. Just kidding. Let's move on. We'll start out with kind of just a company overview. For those of you who don't know us, Glaukos has been around for about a little over 20 years. Our company mission we've got on the big box on the left there where it says, We'll go first. That really comes around because of the DNA of the company. The company was founded back, again 20 years ago, to try and solve a problem in the area of glaucoma.
Back then, glaucoma was treated very simply by if you came in and you were a patient that showed signs of glaucoma, a doctor would prescribe you a set of drops. You would come back after three months, those drops wouldn't be working, you'd get another set of drops, a third set of drops, and finally a fourth set of drops until you just weren't able to manage your pressures on those drops. They would turn to a very invasive surgery where they, to say it in layman's term, would really put a hole in your eye to relieve the pressure of the fluid that was building up on the front of your eye. Our founders thought there had to be a better way to tackle this disease rather than this paradigm that was existing 20 years ago.
They went first in that they designed the first ever stent that was designed to go into your eye and implanted in the back of the eye that would allow the drainage to happen naturally and to get away from these gruesome surgeries to the best that they could and start to manage that. That became the first thing that we innovated, as we say in there, innovation is at the core of everything we do. It solved a solution and a problem that helped patients and helped our customers, which were the physicians, to treat the disease more effectively. You see in the second bullet there, dropless therapies. I mentioned the fact that most of the paradigms back in those days were to prescribe more and more drops.
It was interesting because you'd start on one drop and you'd come in and your pressures were not bad or were getting worse, and you'd do a second drop and a third drop. That was their very common procedure, and it wasn't until data got put together that showed, interestingly, patients weren't taking their drops. Why was that? It's so interesting that 90% of patients, data will show you, just didn't take their drops. It was because of all the side effects and the difficulty in administering drops, and we'll talk about that a little more. Only 50% of patients would refill their prescription, which is crazy. You've been diagnosed with a sight-threatening disease, and one in two would not even fill their second prescription. It was because of the difficulties with drops and the side effects.
We've channeled the company to be around dropless therapies. How can we treat the disease without having to rely on drops? Last but not least, we've talked about being a proven new market pioneer, and that was really because before us, the stents and that business, there wasn't a MIGS category, a Micro-Invasive Glaucoma Surgery category. We built that market based off of the stents, and we've since progressed it to have more products, which we'll talk about over the course of the presentation. Just a little bit about us. On the left-hand side, you can see some of the stats. Last year, in 2025, we had a 30% top-line growth. In the first quarter, we were at 41% growth.
Our 10-year CAGR is 20% growth. We're a high-growth company, always trying to release or innovate and produce more products that get that in the marketplace and continue to top-line grow. We have 12 commercially approved products out in the marketplace today. When we did our IPO just over 10 years ago, we only had one. We've obviously increased that. We have 13 disclosed pipeline products, up from four when we went public. Those pipeline products continue to drive the top-line growth that we experience as we continue to move those things through approvals. We are an R&D company. We pride ourselves in our pipeline and what we're doing and how we're advancing. You can see over the last six years, we've spent almost $1 billion, $800 million, in our R&D efforts as we've continued to develop and produce more products.
On the right-hand side is we've developed the company into a platform type of a situation. We have five distinct platforms upon which we try to do a cascade of products over time to continue that high growth on the top line. We've already talked about our stents, and we've got now we're into our third generation of stents, which is called the iStent infinite. We'll talk a little more about that. iDose, which we'll talk about, is our first sustained pharmaceutical release. We have iLink, which most of you may know as our cross-linking or our keratoconus product, and we'll talk a little bit more about that. iLution, which is a novel drug delivery platform. We talked about the fact that we'd like to stay away from drops, our R&D guys were thinking, is there a way to deliver the pharmaceuticals in a drop through another mechanism?
We thought there might be. We got involved in looking at a cream or we call it a lotion. Think of it that way, that you would just dab a little bit on your finger, put it on your eyelid, and does that effectively deliver the drugs to your eyes as opposed to using a drop. Then last and not least, we're dabbling and dipping our toes into the retina market. We've got a program underway in phase II around retina, but that's a large established market within ophthalmology, and we're excited about that. Today, we're sitting at a point, it's kind of an inflection point in the company's history where we have two revenue drivers, large revenue drivers in these two market areas, which we're calling interventional glaucoma and interventional keratoconus. We'll talk about each of those as we move through.
The first one is just if we think about, and we've talked a little bit about this, the major problem in glaucoma care is this non-compliance with drops. You can see on the left there is the traditional paradigm that I kind of spoke to where you'd start with drops and then you'd add more drops. About a decade ago, the SLTs, which is a laser program, those became more in vogue, so to speak, and was used in this paradigm. Then you still had to go through if that didn't work, and we know from data that about 50% of those lasers fail after two years, about 75% after five years. You're facing these filtration surgeries where they put the hole in the eye and try to drain it that way. I've talked about those stats on the bottom already.
We're driving the marketplace to what's on the right side, which is this new interventional glaucoma treatment paradigm, where it makes sense to now treat these patients interventionally with a procedure as opposed to just reflexively prescribing them a drop, which if used works. We know they just don't use them for all the side effects. You can see there the typical or what we drive towards is this laser treatment as the first-line therapy. Go ahead and do the laser. It's great. It's easy. It's in the office. It's very non-invasive for a patient. Easy to get them into what we're calling the interventional glaucoma funnel, have that conversation. Docs are very comfortable with that. The technology's been around for a long time.
Ultimately, like I said, within five years, 75% of those procedures are going to fail, and that hole is going to disappear, and that pressure is going to start to build up again. Then we would propose that then they move to a procedural pharmaceutical, which is our iDose product, which we'll talk about, where you take the same active ingredient in those drops that slows down the production of the fluid within the front of the eye, implant that into their eye, and let that elute and deliver the drug to the eye instead of relying on the patient for their compliance. That, in our trials, as you'll see, has been very effective in maintaining pressures over a long period of time, as opposed to you having to take a drop every day.
Once you're past that stage, you can add to that with different tools in the MIGS category. We have the stent still that we can complement that. Again, the procedural pharmaceutical is designed to stop the production of the fluid or slow that down. The MIGS or the stent part of the solution is to open up the drainage on the back part of that. You're on the outflow side, and you're being able to continually allow that fluid to flow and not get stuck in there and build up pressure on the front of the eye. You have some MIBS, which is micro-invasive bleb surgery, and then that final end of stage for your really tough eyes, the filtration surgery, sorry. We feel like we, in that paradigm, we're ideally situated to handle it.
We've got these products, which I'll show you right here, that will handle those areas along that journey. It's interesting to note that a glaucoma patient, on average, will be in a practice with that disease for, on average, around 20 years of their life. They get diagnosed somewhere in their mid-60s to 70s. That takes them to the end of life because there is no cure for glaucoma. You've got to manage it as best you can and manage that pressure. On the bottom part of that little pathway area, you've got the stents. We've talked about the stents that will be allowed. We started out in this area of combo cataract. Now we've advanced into standalone with iStent infinite. It allows that drainage to happen through the back part of that front of the eye.
On the top, you've got the iDose, which can be the workhorse in allowing that pharmaceutical to be administered in the eye 24/7, and that is along the whole journey of your disease. It's there, it just takes that compliance danger out of the hands of the patient, and we just put it right in the eye for them. With respect to iDose, it's designed to be long duration. You can see some of the interesting stats on here. One iDose in our pivotal trials was shown to last up to three years for 70% of the patients. You can imagine taking the drops out of the hands of a patient for up to three years, and that shows that they avoid taking drops 2,190 times. You can see that at the bottom. That is a great holiday for those patients.
You talk to any of those patients, they love being off those drops. What are some of the side effects they have? A lot of times it gives them red eyes, so they look like they're hungover. A lot of times it gives them dry eyes, so it's itchy and they hate it. A lot of times it'll give them some fat atrophy in the bottom of their eyes, and so they look just kind of bloated in their eyes. It's not something they like. In fact, we've heard patients come in after having an iDose in three months, and the first thing they say is, Look, doc, look at my eyes. They're not red anymore. They're thrilled to have it. The product in the real world is working exceptionally well. It's gotten great clinical response from our customers on how it's working.
You can see on the right-hand side that 81% of our patients in the clinical trials were free of the topical meds, and we already talked about this fact that 70% were well-controlled after three years. iDose is just the beginning. We talked about the fact that the company's designed on these five platforms, iDose being one of them. Today we have the iDose TR, which is the product that we were just talking about. Coming down that pipeline, we've got two other products that are in the near term. One is called iDose TREO on the left. TREO is T-R- E-O for in-office, and it's really just taking the same iDose canister that we have today and putting it into an injector system that's advanced and much smaller incision site so that the physicians can do it in the office in a much more confident manner.
It is of note, I will say that our existing iDose product today can be used in the office. It does create a slightly larger incision. The iDose TREO is designed to make that smaller, make those surgeons more confident of doing it in the office. We ultimately would like to be site agnostic, meaning if surgeons want to go into a surgery center and an outpatient surgery center setting and do the iDose TR, they can certainly do that. If they'd rather do that in the office with an iDose TREO, we're happy to provide them that opportunity. We're going through the process of the clinical trial with that iDose TREO currently. We'll get the reimbursement codes set up to do that. They'll be free to operate and do those things in the office. The next one is the iDose TREX.
We kind of lovingly call it TREX, although it's T-R-E-X for extended. From a geography standpoint or geometry standpoint, just by bowing out that canister, we're able to introduce about twice as much of the drug into the canister under the theory that it would last twice as long. We're going through the clinical trials on that, where we're hoping to see durations in, let's call it five to seven years, as opposed to three with the iDose TR. So far in the trials and the data that we've seen, it's having a great, robust IOP pressure-lowering effect on our patients. We get into the stents. I talked about iStent infinite.
iStent infinite was the first product that we had that would allow us to go into standalone patients with glaucoma. Going back in the journey, if you recall, we started 20 years ago. We finally were able to get the first stent approved in 2012. The FDA was very hesitant to approve that stent on a standalone basis. They didn't like the idea of a surgeon going into an eye just to implant a stent. They approved it in combination with cataract surgery. For the first many, many years, all of our stents were only allowed to be implanted in combination with cataracts since the surgeon was already going to the eye to replace the cataract. In 2022, we were able to get finally everyone comfortable that these were safe and effective.
We have iStent infinite, which is a three-stent solution that can go into the standalone patient or in combination with cataract, quite frankly, and be used as part of our MIGS offerings to our customers. Lots of data, lots of history there, very safe and effective on use with our patients. As you can see on that little picture, it is very small as well. We think it is the smallest medical device ever approved by the FDA, are these stents. Thinking about the market opportunity, and this goes to what I was just saying. When the company started and we were kind of constrained to the cataract combination market, you can see on the left-hand side, there's five million eyes that get cataract surgery, of which about 10%-15% have glaucoma alongside.
We were playing in a market, let's call it of 500,000 eyes that could potentially get our stent products. On the right-hand side is the overall, let's call it glaucoma market of standalone eyes. You can see that the prevalence data would show you there's 22 million eyes out there that have glaucoma, of which only 13 million are diagnosed, of which 12 million are diagnosed and actively treated. Today, the vast majority are treated with drops, as we've talked about. It's a large opportunity for this glaucoma treatment and why we're so excited about the offerings that we have, both with the stents and with iDose, to tackle this problem and keep people from going blind over time, getting them away from drops and into this more interventional approach.
The vision that our CEO has for the next 10 years with respect to interventional glaucoma and treating these patients, he likes to go back in time, he's been around for a long time, is to talk to the surgeons and get them to buy into this idea of treating patients interventionally. One of the things he thinks about is a lot of these customers, their bread and butter historically has been cataract surgery, and they do a lot of cataract surgery. 20 years ago, when they did a cataract surgery, their professional fee was $2,500. Today, though, as after chipping away of it over the last 20 years, they're only getting paid about $450. The professional fees are shrinking.
As I mentioned, a glaucoma patient is in your practice or potentially in your practice for about 20 years, whereas a cataract patient is typically a one-and-done patient, right? If you can start to have them catch the vision that you're spending today all of your marketing dollars and all of your efforts to acquire a patient for a one-and-done procedure. Whereas if you just shift your paradigm thinking over and focus on glaucoma, of which there's a large market opportunity, and they're going to be in your practice for 20 years, and that'll give you multiple shots to help that patient with different technologies that we have, it can be a win-win for everybody. The second is around combination therapy. I mentioned that the iDose is treating the introduction of fluid in the eye. The stents are treating the outflow side of that fluid.
If you can use them in combination one with another, it's a win-win and a better solution for patients because you're attacking it with two different mechanisms of action. We've got to get the data to support that, we're currently undergoing clinical trials to support that usage. We're hopeful and we're seeing doctors getting more excited about that combination therapy of using, for example, an iStent infinite and an iDose in the same eye in the same procedure. That's certainly, if I could, I'd have my mom do that as well. The next would be this in-office. More and more things around ophthalmology and other med tech are to the extent you can do it in the office. That's where we see things going over time. We mentioned the opportunity that we're pursuing to get the iDose into the office through the iDose TREO.
It just seems like as professional fees and other fees, ASC fees get cut, there's more of a drive to get in the office. It's certainly a much easier conversation with a patient to get them to undergo an intervention in the office. As the steps along the journey, we think in-office will be more and more of a part of the treatment algorithm and the practice. The next would be for us to continue to drive this sustained-release drug delivery over the longer term, so they don't have to do it as often, right? We talked about TREX as that first opportunity, where if we can get it to be double the TR, where a patient only has to have that happen once every six or seven years, that's just better off and probably an easier conversation with them.
PE groups also are becoming an increasingly more important part of this whole environment around ophthalmology in particular, wherein maybe you're seeing it in other practices where the PE groups are buying up small ophthalmology practices and combining them. At least one of the benefits of a PE, if you can say that, is they're very savvy when it comes to financials. They can understand the value associated with some of these patients that are going to be in a practice for 20 years, some of the revenue opportunities that come along with that, with multiple procedures over that journey. We do see and foresee that PE groups will become more and more an important part of this journey along the IG roadmap.
Last but not least, we think that doctors will then pivot over time to become IG specialists, and that they'll advertise as being an IG specialist, and just because the market is being so large and so many patients are out there that they'll want to say to these patients, Hey, we're going to take you off drops. We're going to get you on this IG roadmap, and we're going to get you treated and monitor those pressures and become really good at doing that over time. This is our product roadmap. We've kind of talked about everything on this, except for one thing I'll just point out really quick. The fourth one down is PRESERFLO. That is our micro-invasive bleb surgery product that's in clinical trials now.
We do have it approved outside the U.S., and we get great feedback from surgeons outside the U.S. in using this product. We're hoping it will get through the gauntlet here in the FDA, and we'll have that to be added to the arsenal of what our customers use in the future. Okay, the second area of driver for us from a revenue and a growth perspective in the company is interventional keratoconus. Now, for some of you've probably never heard of it. I'd never heard of it six years when we bought a company that was treating this. Let's talk about what it is. Keratoconus is a disease that affects the cornea and is typically found in younger patients where their corneal fibers are weak, and that causes a bulging out of the cornea that distorts the vision.
Many times, they're kids, they're typically teenagers that start with this. Today, there's just not a lot of awareness about this disease, what it is. You can imagine if you're a mom or a dad and you have a child in high school or middle school who comes home and says, I can't see the board or, I can't see it anymore, the first thing they do is they run down to the optometrist and they stick their kid in front of the optometrist, and the optometrist takes a look and realizes, yeah, they will treat it, not knowing about keratoconus, they will treat it as a visual acuity problem. They'll put them in some glasses, they'll put them in some contact lenses.
What happens is they'll come back in six months. The vision's deteriorated further. They're scratching their head, what's going on? They change the prescription. Just because there's a lack of awareness around keratoconus and what it is. As we see on here, one in five, we think one in five are not being diagnosed accurately with keratoconus. We say that the typical time when this happens is in teenage years. However, today, they're not getting treated until they're in their early 30s because people are just not aware, and they're trying to figure out what's going on. Why is the vision still distorting when I'm putting in contact lenses? What's happening here?
I don't know how many years, I guess it was about 10 years ago, there was a company named Avedro that came out with a product that would stop or halt the progression of this keratoconus with a product called Photrexa. In 2019, Glaukos acquired this company, Avedro, and we started to work through this drug delivery. I guess there's a couple more stats on here. We talked about some of these already. You can imagine. Now, let me just talk a little bit about this product that they had called Photrexa. Photrexa worked. It stopped the progression of keratoconus. It's a drop that was put on the eye, shined with a light that activated a cross-linking effect that strengthened those corneal fibers and held them in place. All sounds great, except for one thing.
In order to make it effective, the surgeon had to debride or scrape off the outer layer of the cornea, something that was painful, and the recovery time was long. When you're faced with losing your vision or having distorted vision, patients were willing to step up, but not in great numbers. You take that, along with the fact that it's a very unknown disease, and there just wasn't a lot of opportunity for us to continue to grow this market. We were treating about, well, let's call it 10,000 patients, about 18,000, 19,000 eyes a year over the six years that we had this product in our bag. Despite what we could do, that's the best that we could do. A lot of that was it was not seen as a rare disease.
Despite it being just 10,000 patients, it wasn't seen initially as a rare disease, and it wasn't priced properly. There was a second generation that was coming around, and it was called Epioxa. This now has been approved. It got approved at the end of last year, and we just launched it in the first quarter. The great difference being that this one, you do not have to remove the outer layer of the epithelium or the cornea. This is a new topical drop that is put on the eye. You shine the light on it, you infuse some oxygen on it, and that does the same effect as Photrexa. It allows for a much better patient experience, obviously. Recovery time is much shorter. The whole treatment time is much shorter. It's a win-win all around for everybody.
The nice or exciting thing about this is it allowed Glaukos to completely reset how we go to market with this disease, keratoconus. The reason I say that is we were offered the opportunity to introduce this as a rare disease drug, price it accordingly, and therefore allow us to have the capital to do the things we need to do to find the patients, to educate the patients, and get them treated so they can stop their disease at an earlier point in time. All of these things that are around this little lady right there are all the things that we're investing in with the new capital that we're going to realize on the higher price with Epioxa that allows us to attack this disease more fulsomely. I can see that the time is going fast, Steve says. Let's get skipping ahead.
You can see the launch timelines. We're in the second quarter right now. We've done a great job in launching the product, creating a patient hub for our patients so that they're taken care of and through their journey, establishing a new site of care network, so we cover them geographically and make sure they have the opportunity to get treatment. We're going through the process now of payer coverage, going out to the insurance companies, replacing the existing Photrexa with the new Epioxa, et cetera, so that we can get patients treated. There's a third generation that comes behind that. I'll just quickly say the idea here very quickly is to take a topography of the eye, find out exactly where the corneal weaknesses are, and selectively target that so that they strengthen the target instead of just a random shotgun approach with Epioxa.
It's going to be more targeted, more of a rifle approach to really get a very customized treatment for each patient with their keratoconus. I'm going to just skip that. We've talked about that. We'll talk quickly about iLution. This was this idea that can you put a pharmaceutical in a cream and put that on your eyelid? We're going after our lead candidate is around the Demodex blepharitis, which is the same market that many of you know with Tarsus, and you've seen the little commercials with the lovely mites crawling around on your eyelids. It's the same idea. Theirs is a drop, ours would be the cream. Can we put a cream on an eyelid or right on top of the critters and kill the critters and attack the disease?
They've done a great job making awareness of that market, and we hope that our product can play in that space as well. Last but not least, we talked about retina. All I'll say here is that it's really early but very encouraging. The idea for us on this play around retina is can we design an implant that will last longer than the two to three months of therapy today? Our rabbit models you can see on the bottom, which are highly applicable to humans, but they can stay out three years. That might be too long for a commercial product. We're trying to dial that in. We've gone into a phase II trial with our retina in biodegradable implant, and we'll see what happens as we go through those clinical trials.
Those are all the pipeline, all the products, everything that's going on in the company. You can see there's a lot happening with Glaukos we're very excited about. The last slide I'll show you really quick are some numbers. You can see the revenue on the top left, how it's a cascading, a nice linear growth there. Our current guidance is $620 million-$635 million for 2026, so that's the midpoint at $627.5 million. Great gross margins, guys. Margins in the mid 80%. With these pharmaceutical products, we expect accretion in the margins over the near and midterm. You can see we're diverse. We not just do glaucoma and cornea health. We also have an international practice that we haven't talked about. Last but not least is on the right-hand corner on the bottom, $281 million of cash in the bank with no debt.
We continue to operate on a cash flow breakeven in the short term. Then soon, hopefully, as these products ramp up, these pharmaceutical products, we'll get to more of the cash flow generation, and we'll go from there. With that, I'm out of time. I'll turn it back over to Steve. Thank you so much.
Yeah. Thanks, Alex. Thank you everyone for joining us. See you over at the Richardson Room for those that can be with us.