Okay, great. Good afternoon, everyone. Tom Stephan with Stifel. Excited to have RxSight here with us today. Pleased to be joined by Ron Kurtz, President and CEO, and Shelley Thunen, CFO. I'm going to dive right in, and I'm going to start with trends. Shelley and Ron, I believe you've said for LAL volumes that April was better than March, and that late April trends specifically were what got better. In our view, that coincided with, I'd say, relatively less macro noise compared to early April. Most importantly, the macro notably seems to be stabilizing even more so over the last, call it, four to six weeks. I guess my question would be, are there any factors we should consider that would prohibit LAL volumes from increasing in May versus April? If we can start there, that'd be great.
Maybe I'll start, Tom. I would say that the, you know, the reason why we made that comment was exactly to your point, that, you know, while premium has historically been relatively resistant to macro trends, specifically things like, you know, recession fears or inflationary pressures, they, you know, in this case, where there is almost a direct effect on equity markets, which disproportionately impacts the older demographic of cataract patients, we were, you know, impacted by that in Q1 and then again in early April. We were making the analogy that you just made, which is that we saw, as that improved, we saw some benefits in our procedural volumes in late April that were consistent with that. At this point, that's all that we've commented on.
I think that, you know, it's great that the trends have continued, and we would, you know, we would hope that they would continue to.
Okay, got it. So when you say the trends have continued, is that sort of, you know, aligning with the macro improvement or?
No, I was just saying that we're happy that the macro trends have continued.
Got it. Okay, appreciate that. And so, you know, with the macro continuing to stabilize, maybe to step away from LAL, and as we try to think about premium IOLs more broadly, you know, as those macro trends have, I'd say, gotten better, you know, how has the premium IOL market here in the U.S. more broadly looked? And in your view, you know, trended in the quarter separate from LAL, the broader market?
I can't comment, obviously, on the current quarter, but I think that we can learn a lot by looking back. You know, now the major companies have all reported for Q1. We've got the data from, you know, into the second half of 2024. I think that, you know, what we had talked about on our Q1 call, I think, has been largely validated that the, you know, that the kind of shocks to the system in Q1 that occurred, you know, in the equity markets, but also more broadly in the overall U.S. environment were impacted not just premium, but cataract surgery volumes as well.
That, you know, improved some as those, and we would hope that improvement would continue as, you know, the equity markets recover, but also as people, I would say, acclimate to a new environment that we're in and that we are adapting as well as probably some moderation going on on that side as well. I think overall premium, you have to look at the premium over the last several years. If you look at premium over the last several years, you see that it's largely been flat, except for the growth of LAL. That makes sense to us because if you look at where the patients for the LAL come from, a large fraction of them are coming from monofocal IOL patients, you know, somewhere in our previous surveys, 40%-45%.
When you look at the growth and health of the premium IOL market, it's largely been driven by the LAL and to a lesser extent by toric IOLs.
Got it. That's helpful. Ron, you said, appreciate your point on kind of the thoughts you conveyed on the market, sort of being validated, you know, since the 1Q call. I would imagine, you know, thinking back since your early April pre-announcement, there's just been more and more learnings as the weeks and months have gone by. I guess, is it becoming maybe more apparent as we sit here today that we'll call it the 1Q shock was a shock? In other words, something more temporary as opposed to kind of durable headwinds in the market? Maybe if you can touch on, you know, kind of that sort of dynamic with the headwinds to premium IOLs in the U.S. being potentially more temporary as opposed to durable or sustainable.
I do not know that I commented on durability or sustainability, but I certainly commented on their association with the macro effects that we just talked about. Those were different than what had been going on previously. Certainly, the reduction in overall cataract and premium were consistent with, you know, that discontinuity in Q1. Now, the question that you are asking is, you know, what is that? How do you predict the future? It depends on, to some extent, on what is going on with those, you know, with those effects going forward and how quickly. My own view, and I think it is shared by some, is that, you know, that we will see moderating impacts of those primarily in the second half of the year.
I think there are a lot of reasons for that, some of which are probably more psychological, some of them are political. The overall trends in premium that have been going on for several years, and even you can go back further than that, where there's been a movement to quality of vision over quantity of vision is a trend that I think will continue. It's been going on for really since for more than 20 years, but has been, I think, highlighted since the introduction of the LAL over the last four years. We believe that that is going to be a primary or the primary driver of growth in the market. That'll be, you know, that's our job is to continue to make the LAL more and more accessible to a larger fraction of the market in the U.S., as well as globally.
Got it. That's great. Pivoting to competition, small handful of questions here, but to kick things off, PanOptix Pro from Alcon has started to roll out. Talk about what you're seeing in these early days from that lens in terms of trialing, sampling, how your customers are reacting, et cetera. I have a follow-up.
You know, obviously, we do not have any specific knowledge about how PanOptix Pro is doing. I think that, you know, what I would comment is that generally, I think there are now for the first time in several years, competitive products in the presbyopia correcting IOL space. Are there any significant differences between these products? I do not see it. If you look at the path for most of the products, which has been FDA supplements, some of them even manufacturing supplements where it is specifically required to say that you are not changing the clinical characteristics of the product, I think that the likelihood that we are going to see any significant clinical difference in these products is small. They do give an opportunity for companies to advance their marketing efforts.
We have talked how some of the companies have, you know, used incentivization programs, which were heavily used, especially in the back half of 2024, in the first quarter of this year. Those are, and that's been something that's been done over the last 20 years, but those also are transient. You know, they're not sustainable. At the end of the day, they're going to mostly impact other presbyopia correcting IOLs. It does not mean that we're immune to it. You know, we get somewhere between 25% and 30% of our patients from patients who would have gotten a presbyopia correcting IOL. Obviously, we are impacted by it, but to a much lesser extent.
If, you know, I think that when people look at the share movements, what they're going to see is that most of that has been amongst the people, the companies that are focused in that market.
Got it. That's great. And a handful of those points, Ron, probably will answer my next question. But, you know, you've talked about confidence in these trialing headwinds starting to abate in the third quarter of this year, I believe. I guess what underpins that confidence around more specific timing, I guess? Why in the back half of this year, especially with PanOptix Pro starting to ramp up, do you believe the trialing headwinds towards LAL are going to start to abate?
Again, you know, we don't know what other people are going to do. You know, historically, Alcon, which makes the PanOptix Pro, has been fairly price disciplined. I think that, you know, they've made comments similar to that over time. I think that that's a strategy that's worked for them. You know, again, we'll have to see what happens in the marketplace. Generally, it's just not sustainable to continue these programs.
Got it. That makes sense. Pivoting to utilization, Ron and Shelley, you talked on the recent call about new programs you're instituting to help with same-store sales or utilization. Can you elaborate a bit more on what this entails more specifically? What are the new programs? What was the impetus of this, given macro seemingly has been the main driver of the recent deceleration in utilization?
I think that while we've definitely ascribed impact from the macro headwinds that we've talked about, as well as the competitive, our opportunity, as we've continued to expand our installed base, is not just to expand, continue to expand that installed base, but it's also to drive utilization at our current customers. That's a lever that we have that can, you know, that becomes more and more significant over time. It's not that this was not an effort of the company beforehand, but it's something that can definitely help counterweight when there are other headwinds in the marketplace. It's certainly something that's under our control. What we've learned both here, as well as, you know, our previous efforts in ophthalmology, is that whenever you introduce a new technology, there's a learning curve that goes along with it.
It's not just a, there's a set of clinical skills and facts that have to be developed by surgeons, by staff in the clinic. There's also practice learnings that relate to efficiencies as well as marketing techniques. The way that you accelerate your adoption in the marketplace, or one of the ways that you accelerate that, is you take the learnings from your higher adopting sites and you bring them to your lower adopting, because everybody has different skill sets in their practice. That's the function of our, you know, clinical trainers and account managing team. We can always do that in a more concerted and effective way. Those are the programs that we've specifically emphasized as we try to leverage our installed base to continue to drive growth.
Got it. So it's bringing best practices from your higher volume centers, trying to kind of translate those to the remaining installed base. You know, when do we think about these benefits starting to show up in LAL volumes or starting to contribute and why? Is there anything that's low hanging fruit, or is this more of a kind of intermediate to longer term type of effort?
You know, I think that generally, you know, things are, you know, anything we do is going to be in the timeframe that we've talked about, that if we're going to, you know, when we see, you know, in terms of our guidance, we said that we were expected to see more of an impact in the back half of the year. You know, I think that's consistent. Beyond that, of course, the efforts that we're describing are not short-term efforts. Therefore, you know, therefore the long-term growth of LAL volume, you know, for many years to come. We're, you know, we believe that the primary growth driver for premium has been the high quality and range of vision that you're able to deliver with the LAL.
We think that that should continue to grow over time and help grow the premium market, which is the only area in ophthalmology really where ophthalmologists and ophthalmic practices have an opportunity to grow their revenue when their revenue is being cut by cuts in reimbursement. It, you know, this is, we think we have the right tool for the right time.
Got it. That's great. Then sticking with utilization, Shelley, maybe this one's for you, but you've talked about how parts of the 2024 class of surgeons haven't come up to speed as quickly as other recent classes. You know, maybe there is potentially a weaker end market at play. What are your latest observations of that 2024 surgeon cohort? We're now, you know, five, six months into 2024. You know, what fundamentally are you seeing with that more recent surgeon class?
Yeah. So, you know, I look at that number of LALs per LDD for each of our classes, you know, quarterly. We do not necessarily look at it monthly. When we look at our overall classes of installs in 2021 and prior, 2022 and 2023, they all end up about the same number of LALs per LDD. They are very close together in terms of their numbers. The distribution is very close. What we did see is in 2023, that class of customers got to the same point in time in each point in time faster than the 2021 and prior and 2022 classes. What we have not seen is that yet in the 2024 class. I have only looked at installs in the first half. You know, really, it becomes more relevant after people have been installed about a year.
Certainly, if I look at where they are right now, particularly in the first, you know, quarter of 2025, which is the installs in the first and second quarter of last year, they have grown at a lower rate of increase than the 2023 class, I am sorry. It is not inconsistent with what we saw in the overall numbers in the first quarter. I want to kind of leave that in front of us. I do not think I will look at the people installed in the third quarter until we get through the third quarter. They are pretty, you know, close to nine to 12 months installed. Let us see how the overall market reacts. I suspect that they are very affected by that as well.
Okay. Got it. That's helpful. Maybe last one on utilization. We look at street estimates, and they currently imply flattish to slightly down utilization in 2Q 2025 versus 1Q 2025. April was better than March. The macro through May has improved, which may bode well for end markets and for LAL. When we look back at 2Q 2024 utilization, it increased high single digits versus 1Q. 2Q 2023 grew mid-single digits versus 1Q 2023. Are there any incremental dynamics we should be aware of this year that would not allow for a sequential increase in utilization in 2Q 2025 versus 1Q 2025? Maybe talk to us about any fundamental factors that, you know, maybe would not allow normal quarter-to-quarter growth this year in 2Q for utilization.
Yeah. And, you know, we think that metric is relevant, but we certainly do not guide or run the business on that metric. I think what is more important for us is one, market share. You know, now that we have gotten a little bit larger and Ron talked about earlier, you know, that if you pull out the LAL from the quantity volume in the U.S., the market has been flat to down, whereas the growth in overall premium in the U.S. has come from the LAL. I think that that is an important factor. You know, we ended the fourth quarter at about 10%. Looking at the numbers for the first quarter, we might be about 11% or 12%. That is just a function of the market. We continue to grow when the overall market did not. I think that is the important part for us to look at.
Going back into the first half of 2024, that was extraordinarily strong, right? It was a little weaker in the second half, but still very good. It just was not as high as growth. We have guided that the number of LDDs would be higher than 24 in 2025, not specific numbers. We had a really strong LDD sales number in the first quarter. You always kind of have to take in those factors as well. What we are looking for is absolute growth in numbers and absolute growth in market share. I think that is relative to the overall market. We will not know that, you know, until probably after, well after we report, you know, four to six weeks after we report our second quarter results.
Okay. Got it. Really helpful color. Shelley, you mentioned LDDs. Wanted to ask a couple of questions there. To your point, LDD placement growth was solid again in Q1. Premium IOL end markets seemingly maybe softened a bit or have softened of late. As you look at your pipeline and your sales funnel, as we sit here today, are you sensing or seeing any sort of increased capital equipment purchasing hesitancy or trepidation? Maybe if you can talk to, you know, real-time observations in the funnel.
Yeah, I think, you know, when we look at overall funnel for LDDs, it remains relatively stable. And remember, of course, LDD sales tend to happen like all capital at the end of the quarter. That is just the way industry has trained people to behave, you know, doctors and others. Nothing looks different to us this quarter than it has in previous quarters. That has always been, you know, the way the operation goes. You know, the thing to keep in mind for us is the payback for an average doctor is about six months. That is very quick as well. The impetus to buy is really about, you know, patient care, better results for patients. Also, they are making more money with the LAL, right?
Because about 75% of the patient population that's treated with an LAL is coming from people who would have otherwise gotten a monofocal or a lower payment to the doctor with a toric. I think that they have to just be ready to take advantage of being able to grow their practice. Ron, do you add anything? I think we're at time.
Nope. Thank you so much, Tom.
That's great. If I can squeeze in one more question, just on guidance, you know, for overall 2025 sales guidance, you talked about LDDs being up year over year versus 2024. I think the low end of guidance assumed utilization rest of year was flat versus 1Q 20 25. But then the high end, you'll hopefully see consumer stabilization, competitive trialing start to abate. So I guess my question is, has your confidence in achieving the high end of 2025 guidance increased over the last several weeks and months with at least a more stable macro today relative to even the time of your 1 Q call? Maybe you can talk about kind of confidence in the high end of that guidance as we think about the macro improvement.
Yeah, I think, you know, first of all, I do not want to imply that it is utilization, LALs per LDD, right? Because that can be a variable number. What I typically try and talk about is absolute volume, you know, quantity as well. I think that, you know, where we have guided is that we would expect the second half to be the growth half of the year, right? Rather than this first half. That really requires kind of two things. One is that we have some stability politically and in the economy and particularly the stock market, right? People act when they feel confident that the macroeconomics are not going to affect them. I think we still got some time in that as well. We also believe that the trialing has to end at a certain point, as Ron said.
It's not economically viable for the competitors. Those would be the two things that would drive us into the higher end of our guidance.
Got it. That's perfect. Great note to end on. Ron, Shelley, thank you guys so much. Great seeing you.
Thank you.
Thank you. .
All right. Take care.