Glaukos (GKOS) Q4 2025 Earnings Call Transcript

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Date

Feb. 17, 2026 at 4:30 p.m. ET

Call participants

• Chairman & Chief Executive Officer — Thomas William Burns
• Chief Financial Officer — Joseph E. Gilliam
• Chief Operating Officer — Alex R. Thurman
• Vice President, Investor Relations & Corporate Affairs — Christopher Lewis

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Takeaways

• Consolidated net sales -- $143.1 million in fiscal Q4 (period ended Dec. 31, 2025), up 36% reported and 34% constant currency, in line with the preannouncement.
• Annual net sales -- $507.4 million for fiscal 2025, representing 32% growth.
• 2026 sales guidance -- Reaffirmed at $600 million to $620 million, implying over 20% year-over-year growth at the midpoint.
• U.S. glaucoma franchise -- Fiscal Q4 net sales of $86.4 million, up 53%, largely driven by iDose TR sales of approximately $45 million.
• iDose TR sales (full year) -- Generated approximately $136 million in fiscal 2025, with management citing “strong physician adoption.”
• iDose TR label update -- FDA labeling supplement now allows unlimited readministration in eligible patients.
• International glaucoma franchise -- Fiscal Q4 net sales of $32.8 million, up 18% reported and 13% constant currency, driven by broad-based growth and iStent Infinite's EU launch.
• Corneal health franchise -- Fiscal Q4 net sales of $24 million, up 12%, with Photrexa accounting for $21.4 million; Epioxa received FDA approval during the quarter.
• Epioxa launch readiness -- O2n capital systems deployed at locations covering nearly 50% of the U.S. population, with expansion underway toward 90% coverage.
• Payer engagement for Epioxa -- Communications completed with insurers representing approximately 50% of U.S. commercially covered lives, including early positive coverage determinations.
• iDose sequential growth -- CFO Joseph E. Gilliam said, “I think it was north of 10% sequentially” in fiscal Q4, with continued sequential quarterly growth expected throughout 2026.
• Operating expenses guidance -- For 2026, expected mid-teens percentage growth to approximately $555 million to $560 million, targeting operating leverage and cash flow breakeven.
• Epioxa J code status -- Permanent J code submission completed, expected to become effective July 2026; initial availability under a miscellaneous code anticipated to temper early adoption.
• Patient access investments -- New financial co-pay assistance programs and specialty pharmacy options are operational for the Epioxa launch.
• Pipeline progress -- Multiple clinical milestones advanced, including iStent Infinite PMA pivotal trial completion, iDose TReX Phase 2b/3 enrollment, and GOK-401 first-in-human enrollment.

Summary

Glaukos (NYSE:GKOS) achieved record quarterly and annual sales, underpinned by strong iDose TR adoption and strategic momentum in both glaucoma and corneal health portfolios. Management emphasized readiness for the commercial launch of Epioxa, highlighting broad payer engagement and rapid deployment of capital equipment intended to support access for the majority of the U.S. population. Key guidance details point to continued mid-teens operating expense growth and targeted operating leverage as the company prioritizes disciplined investments in new launches and R&D pipeline expansion.

• The fiscal Q4 call detailed deployment of a $0 co-pay program for commercially insured Epioxa patients and robust reimbursement support efforts.
• Management specified that readministration of iDose TR was not a material input in 2026 guidance but is expected to become increasingly relevant in subsequent years as the initial patient pool matures.
• International glaucoma growth is expected to remain at high-single digits, with competitive product trialing anticipated to create headwinds later in 2026, partially offset by iStent Infinite expansion following EU MDR certification.
• Leadership reported that corneal health revenue will show volatility due to the transition from Photrexa to Epioxa, with “modest growth” projected for 2026 and the strongest impact anticipated post-J code implementation.
• Management stated that most surgeons are already experienced with MIGS techniques. Administrative infrastructure and reimbursement are the remaining bottlenecks to broad iDose adoption.

Industry glossary

• MIGS (Micro-Invasive Glaucoma Surgery): A category of surgical procedures using minimal incisions and micro-scale devices for glaucoma treatment.
• PMA pivotal trial: A critical study required for FDA Pre-Market Approval submission, intended to demonstrate safety and efficacy of a medical device.
• J code: A reimbursement billing code used by payers to identify specific drugs or biologicals; a permanent code streamlines access and claims processing.
• O2n system: Proprietary equipment deployed for Epioxa procedures, designed to deliver an oxygen-enriched therapeutic activated by UV light.

Full Conference Call Transcript

Christopher Lewis: Similar to prior quarters, the company has posted a document on its Investor Relations website under the Financials and Filings, Quarterly Results section titled “Quarterly Summary.” This document is designed to be read by investors before the regularly scheduled quarterly conference call. To ensure ample time and opportunity to address everyone's questions, we request that you limit yourself to one question and one follow-up. If you still have additional questions, you may get back into the queue. Please note that all statements, other than statements of historical facts, made on this call that address activities, events, or developments we expect, believe, or anticipate will or may occur in the future are forward-looking statements.

These include statements about our plans, objectives, strategies, and prospects regarding, among other things, our sales, products, pipeline technologies and clinical trials, U.S. and international commercialization, market development efforts, product approvals, the 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. Please review today's press release and our recent SEC filings for more information about these risk factors. You will find these documents in the Investors section of our website at www.glaukos.com. Finally, please note that during today's call, we will also discuss certain non-GAAP financial measures, including results on an adjusted basis. We believe these financial measures can facilitate a more complete analysis and greater transparency into Glaukos Corporation’s ongoing results of operations, particularly when comparing underlying results from period to period.

Please refer to the tables in our earnings press release available in the Investor Relations section of our website for a reconciliation of these measures to their most directly comparable GAAP financial measure. With that, I will turn the call over to Glaukos Corporation’s Chairman and CEO, Thomas William Burns. Okay. Thanks, Christopher Lewis. Good afternoon, and thank you all for joining us. Today, Glaukos Corporation reported record fourth quarter consolidated net sales of $143.1 million, consistent with our preannouncement last month, up 36% on a reported basis and 34% on a constant currency basis versus the year-ago quarter. For the full year 2025, consolidated record net sales of $507.4 million grew 32% versus 2024.

We are also reaffirming our full-year 2026 net sales guidance range of $600 million to $620 million, which implies continued strong year-over-year growth of more than 20% at the midpoint. Our record fourth quarter and full-year results reflect a highly successful year of global execution across our key commercial and development initiatives and underscore the dedication of our global teams, strength of our differentiated technology platforms, and our evolution into a more diversified ophthalmic leader. From a corporate perspective, 2025 was a milestone year. In addition to surpassing $500 million in annual sales, we celebrated our tenth anniversary of our 2015 IPO, surpassed 1,000 employees worldwide, and broke ground on a new facility in Huntsville, Alabama.

As we enter into 2026, we are well positioned to sustain our strong growth momentum

Thomas William Burns: led by two transformational growth drivers, including the continued advancement of the interventional glaucoma treatment paradigm with iDose TR, along with the launch of Epioxa, opening up a new paradigm in interventional keratoconus and rare diseases. These two highly differentiated and durable market opportunities underpin our confidence to deliver a best-in-class growth profile extending well into the next decade as we continue to invest in and advance a robust, industry-leading pipeline while remaining disciplined in capital allocation focusing on ROI-driven investments and cash flow. Our record fourth quarter results are a testament to the progress we continue to make in advancing our mission to transform vision therapies for the benefit of patients worldwide.

Within our U.S. glaucoma franchise, we delivered record fourth quarter net sales of $86.4 million on strong year-over-year growth of 53% driven by growing contributions from iDose TR, which generated sales of approximately $45 million in the fourth quarter. iDose TR’s positive clinical outcomes continue to generate momentum with sales of approximately $136 million in 2025, reflecting strong physician adoption and reaffirming the patient impact of this game-changing therapy. Operationally, our teams continue to deliver well on our plans, focused on growing trained surgeons and accounts, increasing utilization, broadening market access, expanding the clinical evidence, and accelerating targeted marketing investments.

We believe iDose TR remains early in its overall adoption curve with significant value yet to be unlocked as we expand market access and build on the progress of 2026 and beyond. Last month, we were pleased to announce the U.S. NDA labeling supplement allowing for unlimited readministration of iDose TR in patients who maintain a healthy cornea. We welcome this important labeling enhancement and believe it should help expand access for patients who may benefit from repeat treatment and provide physicians with greater flexibility in managing their glaucoma patients over time. iDose TR is the foundation.

Our goal to advance and improve glaucoma treatment by driving earlier intervention continues to gain steam as we educate surgeons and thought leaders globally to organically drive this broader evolution in the standard of care for the benefit of patients. While we remain in the early stages of these interventional glaucoma efforts, we are encouraged with the increasing levels of clinical interest for this paradigm-changing evolution. Moving on, our international glaucoma franchise delivered net sales of $32.8 million on year-over-year growth of 18% on a reported basis and 13% 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 MIGS forward as a standard of care in each region and major market in the world. As previously discussed, we continue to expect new competitive product trialing headwinds in some of our major international markets as we progress through 2026, partially offset by growing contributions from iStent Infinite following its EU MDR certification and associated European commercial launch late last year. And finally, our corneal health franchise delivered net sales of $24 million on year-over-year growth of 12%, including Photrexa net sales of $21.4 million.

As you know, during the fourth quarter, we were delighted to announce the FDA approval of Epioxa, a novel groundbreaking advancement in corneal cross-linking for the treatment of keratoconus, a rare sight-threatening disease that is currently far too often undiagnosed and untreated. Interest from the physician community following approval has been very encouraging and reinforces our view that with Epioxa, we are ushering in a new standard of care for keratoconus patients and practitioners with the first and only FDA-approved topical drug therapy that does not require removal of the corneal epithelium, the outermost layer of the front of the eye.

As a reminder, Epioxa utilizes a proprietary combination of an oxygen-enriched novel therapeutic that is bioactivated by UV light in an incision-free procedure. It is the result of more than a decade of research focused on slowing or halting the progression of keratoconus while significantly improving patient comfort and minimizing recovery time to provide a new way forward for patients afflicted with this sight-threatening rare disease. As we have discussed, the FDA approval of Epioxa has allowed us to reset and redefine our go-to-market approach to better address this sight-threatening disease and truly expand patient care and access.

Immediately following approval, our cross-functional teams commenced execution of our detailed, methodical initial commercial launch plans ahead of Epioxa drug availability expected later this quarter. Importantly, with this launch, we plan to substantially increase our investments in patient awareness, education, and access while addressing the longstanding challenges of underdiagnosis and undertreatment that have affected this rare disease community. Our efforts are designed to support patients and families at every stage, from awareness and diagnosis through ongoing treatment, making the entire journey as seamless, efficient, and patient-friendly as possible over time.

As with all pharmaceutical launches, initial patient access will be gated by our site-of-care network deployment and typical payer adoption headwinds and hurdles, but we are investing in the infrastructure, teams, and processes necessary to get Epioxa to as many patients as soon as possible in 2026 and beyond. We have been encouraged by the progress we have made in short order following approval. First, I am proud to report we are ahead of schedule in establishing our Epioxa sites-of-care network.

Early wave-one efforts are yielding results, with acquired O2n systems already actively deployed at locations covering nearly 50% of the U.S. population and a broader pipeline of systems moving through the approval processes that would expand our treatment center reach closer to 90%. Looking ahead, we will continue evolving this network to bring treatment access closer to patients as reimbursement and drug acquisition pathways become further established and streamlined. Next, on the market access front, we have completed our initial payer communications and updated key payer databases with the details associated with the Epioxa launch.

Our payer team is already actively engaged today with insurers representing approximately 50% of commercially covered lives in the United States, including four of the top five commercial payers. As a result, we have seen several early positive coverage determinations spanning across the Medicaid and commercial payer landscape. We successfully submitted for the permanent J code and expect it to become effective in July 2026 based on the CMS cycle for J codes. Until then, we anticipate Epioxa will be commercially available under a new technology miscellaneous J code and anticipate measured adoption over this initial period until the permanent J code is in place.

In addition, we have also rolled out various new patient services and support programs led by our patient access liaison teams designed to streamline care coordination, demystify the insurance approval process, and advance coverage decisions where possible. The teams are also deploying new marketing and DTC campaigns designed to significantly enhance awareness, education, and detection, driven by increased engagement with the optometric community, the development of a handheld KC screening device, and expanded advocacy partnerships alongside new patient education efforts to identify and reach patients earlier. Finally, as we have discussed, with the launch of Epioxa, a critical focus of ours is to improve patient access to this sight-saving keratoconus treatment.

On that front, we have successfully deployed a new financial co-pay assistance program for eligible patients and operationalized a comprehensive specialty pharmacy option available for our customers at launch. As you can see, we are very excited by the significant potential Epioxa offers to patients living with keratoconus and believe it will deliver exceptional value to patients, providers, and the healthcare system. This enthusiasm was on full display during our recent national sales meeting. Anticipation for Epioxa’s availability later this quarter was palpable. We are proud to lead the way once again in forging a new path to drive expanded patient access and enhanced treatment standards.

Beyond Epioxa, we continue to advance a broad and differentiated clinical pipeline across our five novel therapeutic platforms, with several notable milestones. Within our iStent surgical glaucoma platform, we completed patient enrollment in a PMA pivotal trial for iStent Infinite in mild to moderate glaucoma patients during the fourth quarter and continue to advance a 510(k) pivotal study for the PreserFlo MicroShunt. Within our iDose platform, patient enrollment is well underway in the Phase 2b/3 clinical program for iDose TReX, our next-generation iDose therapy, with initial results of our Phase 2a clinical trial demonstrating substantial IOP reductions of 8.6 to 10.8 millimeters of mercury through three months.

In addition, we recently commenced a Phase 3b study for iDose TR-IO and continue to advance several Phase 4 studies. Within our iLink platform, we plan to bring a KC screening tool to market later this year and initiate a Phase 3 program for a third-generation iLink therapy next year. Within our iLution platform, we commenced the Phase 2 study for iLution Demodex blepharitis in the fourth quarter. And finally, within our retinal platform, we recently completed enrollment in a first-in-human clinical development program for GOK-401, our intravitreal multi-kinase inhibitor retinal program, in patients with wet AMD.

Despite being a relatively young company, Glaukos Corporation has invested over $1 billion in R&D since inception to develop a robust pipeline focused on chronic and rare ophthalmic diseases. Our continued investment in R&D remains best-in-class, underscoring our commitment to going first and advancing the standard of care for ophthalmic patients worldwide into the future. In conclusion, at Glaukos Corporation, we are in the business of pioneering entirely new marketplaces within ophthalmology. Innovation is at the core of everything we do as we advance our mission to transform vision therapies that can meaningfully advance the standard of care and improve outcomes for patients suffering from sight-threatening chronic eye diseases.

Our mantra of “we will go first” embodies our commitment and determination to take chances, push the limits of science, and disrupt the legacy treatment paradigms in glaucoma, rare disease, and retinal diseases through our pursuit of game-changing innovation. Our record fourth quarter and full year 2025 highlight the strength of our strategy and execution as we continue evolving into a diversified ophthalmic leader with multiple transformational growth drivers in iDose TR and Epioxa and advance our mission to transform vision therapies for the benefit of patients worldwide. So with that, I will open the call for questions. Operator?

Operator: At this time, if you would like to ask a question, press

Thomas William Burns: star then the number 1 on your telephone keypad.

Operator: To withdraw your question, simply press 1 again. Your first question comes from the line of Thomas Stephan with Stifel. Please go ahead.

Thomas Stephan: Great. Hey, guys. Thanks for taking the questions.

Joseph E. Gilliam: First one on Epioxa. Thomas Stephan, you mentioned early positive coverage determinations from commercials and Medicaid, I believe you said. Can you elaborate on the key highlights here a bit? And then just broadly, to what extent has there been any payer pushback on pricing of Epioxa and/or the Photrexa discontinuation? Hey, Thomas Stephan. It is Joseph E. Gilliam. I will start off there. Thomas William Burns can add comments if he certainly can. From a payer standpoint, it is important to remember that you really start to get a lot more of the coverage policies in place once you have got drug in channel and you are actually adjudicating the claim.

In the early days, it is all about the clinical education associated with the product, making sure those payers understand what Epioxa is, what it means for patients, and how that is differentiated from Photrexa that they have obviously known for several years now. So when we said that there is a positive development in terms of early policies, it is really because it is even a bit surprising. In the context of a normal drug launch here, in this case in pre-drug-in-channel, you are getting positive outcomes with a handful of Medicaid societies as well as with one of the larger Blue plans out there.

And so all of the conversations so far have been much more clinical in nature. We have not heard any formal or informal pushback from payers on the pricing dynamics associated with Epioxa. So we continue to move forward and look forward to obviously getting the drug officially launched, if you will, and engaging on a claim-by-claim basis with these payers and ultimately getting it to a place where many more have the positive coverage determinations that we expect.

Thomas Stephan: Got it. That is great. And then

Thomas M. Stephan: second question on iDose. Joseph E. Gilliam, maybe just stick with you. Can you talk a bit about the key factors that drove the sequential deceleration in revenue in 4Q now that there has been some time to digest, and maybe more importantly, what is your level of confidence in continued sequential growth here in the first quarter? Maybe you can speak about how to think about, I guess, iDose growth directionally in 1Q as well as throughout 2026? Thanks.

Joseph E. Gilliam: Yes. Sure, Thomas Stephan. I think from an iDose perspective in the fourth quarter, and we talked a little bit about this at a recent conference, we did see a couple of factors up. So we did continue to grow sequentially and grow nicely. I think it was north of 10% sequentially. But underlying that were a couple dynamics worth calling out. The first is that in the fourth quarter, and this is learning a little bit for us in the context of iDose, the mix shifts a little bit towards Medicare Advantage.

There is a lot more volume done in the fourth quarter typically in ophthalmology because a lot of those benefits, and I will call it the piece out-of-pocket dynamics and related, you tend to see a little bit more on the Medicare Advantage side relative to the fee-for-service patient population. The second was just some specific things at Glaukos Corporation, and I will call it our rep incentive, that looking back, we saw probably a little bit of pull into Q3 and a little bit of pull out of Q4, but on the margin, I think also impacted that.

If you think about translating that moving forward, I think what I would say is we do expect continued progress sequentially into the first quarter with iDose, despite it being a seasonally low quarter for procedure volumes. And as the overall year, which we can talk more about throughout the year, we expect there to be continued sequential improvement each quarter throughout the 2026 time period.

Thomas M. Stephan: Great. Thanks, Joseph E. Gilliam.

Operator: Your next question comes from the line of Adam Carl Maeder with Piper Sandler. Please go ahead.

Adam Carl Maeder: Hi. Good afternoon. Thank you for taking the questions, and congrats on all the progress.

Adam Carl Maeder: Maybe picking up, Joseph E. Gilliam, a little bit where we just left off, wanted to ask about topline guidance for FY 2026, the $600 million to $620 million, and really just hoping you can pull apart some of the different components, whether it is iDose contribution, how you are thinking about the U.S. stent business, and corneal health with Epioxa. Any quantitative color would be fantastic, but even just broad qualitative strokes, such as we expect this business to grow or not grow, would be really helpful. And then I had a follow-up. Thanks.

Joseph E. Gilliam: Yes, happy to do that, Adam Carl Maeder, and maybe I will start off. And, obviously, if you have both questions or others, we can dive a little bit deeper. But if you think about the guidance that we have set and affirmed here today, which is normally the time when we set it the first time, as many of you know, no question 2026 is another pivotal year for us, as our efforts, as you heard Thomas William Burns say, to transform the standard of care in interventional glaucoma with iDose and iStent Infinite are kind of now finally joined by what I will call a complete reset and expansion of our investment to launch Epioxa.

And so we were pleased to be able to establish an initial guidance range of $600 million to $620 million, which, at the midpoint, represents more than $100 million of growth in this year. If you think about it by franchise, I think it is probably the easiest way to start. On the international glaucoma side, we expect high-single-digit growth internationally for the year, as competitive launch headwinds really play themselves out in several of our key markets as we have talked about for a couple quarters now, and they are somewhat offset by iStent Infinite launches and the broader interventional glaucoma and market access initiatives that we have going on worldwide.

I think in the early part of the year, that will be a little bit higher than that, and then if some of the currency tailwinds wear off, we would certainly expect that to come in a little bit on the back half of the year. On the U.S. glaucoma side, embedded in the guidance is growth in the 30% range year over year, driven entirely by iDose TR. I think as we have said in prior calls, I think it is safe to start off this 2026 assuming that the non-iDose business is flat on a year-over-year basis, and so the entirety of that growth I am talking about is really being driven by iDose.

And that leaves corneal health. And while there are a fair number of moving parts associated with the launch of Epioxa and the transition from Photrexa, I think we can confidently say we continue to expect that the franchise will grow modestly year over year, with a fair amount of volatility, particularly in Q2 and as we enter into Q3, as Epioxa becomes available and that permanent J code is established.

You will see the warehousing effect that we have been thinking about and the delay as those patients are working their way through the approval process and ultimately getting approval and treatment as we make our way through Q3 and certainly into Q4 when we think the strongest results will be for that business.

Adam Carl Maeder: That is really helpful, Joseph E. Gilliam. Appreciate all the color. And maybe just for the follow-up, I guess another modeling question, and just wanted to ask for a little bit more color on cadence quarterly, realizing you just gave a little bit there. But for Q1, I have the Street modeling, I think, $132 million, $133 million of revenue, which is down sequentially quarter over quarter. Just curious if you have any reaction to that figure. And obviously, Epioxa transition is a little bit, I think, tough to pin down, so any more color you can give us on how you are thinking about sequencing would be appreciated. Thank you.

Joseph E. Gilliam: Yes, Adam Carl Maeder. And it obviously is a bit tricky on the cornea side, but I will zoom out for a second. I think for 2026, we will probably deviate a little bit from those historical norms. You have been around the story for a while; you know that ophthalmic procedures tend to see seasonality of, call it, 22% to 23% in the first quarter, and 24% to 25% in Q2 and Q3, and then 28% plus or minus in Q4. You look at what is driving it for us, it is really based on the two primary factors you might expect.

With the iDose launch, as I mentioned earlier in the call, we continue to expect sequential growth quarterly throughout 2026. That will lead, obviously, to incrementally having more back-half-weighted iDose contribution in U.S. glaucoma. Then from a corneal health perspective, I alluded to it in your first question, but

Adam Carl Maeder: we expect to see modest growth

Joseph E. Gilliam: in the first quarter, as folks continue to do Photrexa procedures in advance of Epioxa being available. I think we will see a fairly material dip in Q2 as we really are in the heart, I will call it, of the transition from Photrexa to Epioxa. Those patients are being entered in for the approvals and prior authorizations, but perhaps not treated at the clip that we will start to see with the J code as we make our way through Q3.

I think Q3 will probably be a bit more of a flattish year-over-year quarter as the J code comes online, you see some of the patients moving out of the funnel and into treatment towards the latter part of that quarter, and then, obviously, we would imply that as a pretty strong exit in the fourth quarter as the J code comes online and we start to see a little bit more normalized treatment patterns as we are exiting the year heading into next.

And if you think about that for just the first quarter in the way you said that, I think the U.S. glaucoma business will probably be somewhat flat to Q4, as the non-iDose seasonality headwinds are offset by iDose itself. Cornea, as I mentioned earlier, will probably be modest growth on a year-over-year basis. And international glaucoma we will see as more normalized, so I think we will see the same high-single-digit to maybe low-double-digit growth on a year-over-year basis.

Adam Carl Maeder: That is perfect. You gave a lot of great color. I will leave it there. Thank you.

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

Ryan Benjamin Zimmerman: Hey, guys. Thanks for taking the questions. I am going to

Ryan Benjamin Zimmerman: try and do a little lightning round here and see if I can squeeze a few in. And they should be easy to answer, but the first one is just around how you think about the interplay between the readministration of existing iDose and TReX and just how you think about whether there is a cannibalistic effect there. And then, just for clarity, you called out 50% coverage on 50% covered lives. You are just in dialogue with those payers right now. And I will just leave it there for now.

Joseph E. Gilliam: Okay. I will start with the second part of your question, and if Thomas William Burns wants to jump on the readministration, he can. So as it relates to the Epioxa coverage, remember, in rare disease and unmanaged categories, it is quite common that you will not have any formal coverage policy. You are monitoring actual prior authorizations and approvals to therapy over time to determine that you have actually got access. That access may come in the form of formal coverage policies, and it may come in informal ways just through simple adjudication patterns that you will have the confidence that patients who seek that therapy are able to get it if they qualify.

So we are ahead of that time, and I think what Thomas William Burns was saying in the prepared remarks is that we have engaged in a meaningful way in clinical conversations with payers that represent over 50% of those covered lives. And as a result, we have even got some early positive policy wins.

Ryan Benjamin Zimmerman: It is important to remember that cross-linking as the standard of care

Joseph E. Gilliam: is not new. We have obviously been at that for some time with Photrexa and the epi-off procedure. And so as we move forward here, we certainly expect them to continue to recognize that and provide the access that these patients deserve on a clearly superior therapy in the form of Epioxa. As it relates to readministration and interplay between that and

Ryan Benjamin Zimmerman: TReX, I think if we if you are thinking about that, if the question was meant to

Ryan Benjamin Zimmerman: be from a long-term kind of modeling standpoint,

Joseph E. Gilliam: Ryan Benjamin Zimmerman, clearly, the goal has always been to provide patients and surgeons with as many options as possible. And depending upon the disease severity and where things are at clinically,

Ryan Benjamin Zimmerman: we certainly expect different surgeons to have different algorithms around

Joseph E. Gilliam: whether they choose to readminister a patient with iDose TR or TReX upon the clinical profile that exists with TReX when we ultimately get it through the FDA process.

Ryan Benjamin Zimmerman: I think about it from a modeling standpoint,

Joseph E. Gilliam: Ryan Benjamin Zimmerman, part of that is to think about, obviously, there is a trade-off there potentially on duration. We have to prove that through the clinical trials. And there are the pricing considerations around a longer-acting therapy as well. And ultimately, I think where we land is most importantly, we now, hopefully with the approval of TReX, have multiple options for patients to remain on sustained pharmaceutical therapies for the duration of their life, if you will, with the disease, which the average patient from diagnosis until no longer needing therapy will be in a glaucoma surgeon's care for over 20 years.

There will be multiple shots that continue to treat these patients, whether it is with TReX or TR.

Ryan Benjamin Zimmerman: And, Joseph E. Gilliam, just a follow-up. Are you going to let Alex R. Thurman just spend uncontrollably for this Epioxa launch? And I am wondering if that is a subtle way of asking Alex R. Thurman what your thoughts are on operating expense spend in 2026 as you prepare for this Epioxa launch. Because it is going to, I think, be a question around margins and operating profit and so forth. Which, frankly, I do have you start to show some profitability in late 2026 despite your ability to spend aggressively here?

Alex R. Thurman: Well, let me step in before Joseph E. Gilliam speaks for me, Ryan Benjamin Zimmerman. And that is right. That is the three questions you asked. Let us talk about OpEx first and foremost. Our philosophy as a corporation still has not changed from what we experienced in 2025, which is we are going to continue to balance our capital investments against our revenues such that we are driving towards cash flow breakeven and potentially some cash flow generation over the course of 2026. And with that in mind, you would expect to see our operating expenses have growth next in 2026.

If you think about what does that growth look like, what I would tell you today or what I would guide to is somewhere in kind of a mid-teens year-over-year growth percentage off our base of 2025. That should put you in the neighborhood of operating expenses around $555 million to $560 million in 2026. Now that is still going to show operating leverage in 2026, which is another of our goals as we continue to march forward within the business and what we are trying to achieve. So that is kind of where we are thinking. Again, those are the key things.

Alex R. Thurman: That, even though

Alex R. Thurman: we are doing this, we have these two really key growth drivers that we are investing in Joseph E. Gilliam’s organization between the iDose launch and the Epioxa launch. Then we have what we believe is a best-in-class R&D pipeline that we have to invest in as well. And all those things are driving our decisions around our capital allocation.

I think there is no question for all of us, Ryan Benjamin Zimmerman, that with the Epioxa launch and the reset month, this comes with a significant investment in patient access, and whether that is on the hub, with the specialty pharmacy, with the DTC investments, or all the various things that are designed to drive awareness, the diagnosis, detection, and ultimately pull-through of these patients in as fast a time as possible. We are prepared to make those investments, obviously within the framework that Alex R. Thurman alluded to.

Ryan Benjamin Zimmerman: Yeah. Thank you. Appreciate taking the question.

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. One on iDose, one on Epioxa. So on iDose, on the repeat label, how do you think about the percent of de novo patients who will get a second iDose, and how do you think about the potential halo effect of this repeat dosing label to new iDose starts? And I had one follow-up. Well, I think, Larry Biegelsen, from a readministration, we are going to have to watch that in terms of those patients. Certainly,

Joseph E. Gilliam: we have actually already seen our first readministration happen in the OR, and it is driven by the things that you would hope to hear, which is that the patient themselves was seeking that. You know, an early patient who was into the area where they would potentially benefit from an incremental administration, and they were seeking it because they did not want to go back on drops. They appreciated the value, if you will, of having the iDose working for them. And so I think over time, we will have to continue to monitor that.

But clearly, if you go back to what I said earlier, if the average patient is in the care of a glaucoma specialist or a comprehensive doctor for a little over 20 years with the disease, we expect there to be considerable, multiple readministrations within the same patients over time. And I think that can certainly be a significant part of the overall mix relative to first-time therapy, certainly as we get further and further out into the planning period.

And I do think that there is an incremental halo effect because, in a baseline, surgeons can confidently have the conversation with patients about interventional glaucoma, knowing that they have got tools and solutions, including the repeat administration of iDose, with those patients to manage their disease that way for, hopefully, their life.

Larry Biegelsen: That is helpful. Joseph E. Gilliam, on

Larry Biegelsen: Epioxa, can you talk a little bit about

Larry Biegelsen: how quickly you expect to upgrade accounts to the new capital equipment, and can you put a finer point on when Photrexa is expected to be completely phased out? Thank you.

Joseph E. Gilliam: Yes. As you heard in the prepared remarks, we are already well down that path of at least installing the capital equipment required to administer Epioxa. We would expect that journey to continue. I think as Thomas William Burns mentioned in the remarks, we have already installed or are installing capital equipment at locations that would cover over 50% of the lives in the United States, and we have got various levels of approvals in various systems and providers where we will be north of 90% as we make our way through here in the launch. So I think we feel really good about where we are at in establishing that foundation, if you will, as we move forward.

As it relates to Photrexa and the transition, it makes sense, Larry Biegelsen, without getting too specific on dates, that with a July 1 J code, we want to make sure that Photrexa certainly remains available to physicians through that period. And then, as we make our way into and through the third quarter, we would expect to transition that more fulsomely over to Epioxa.

Larry Biegelsen: Thank you.

Operator: Your next question comes from the line of Allen Gong with JPMorgan. Please go ahead.

Allen Gong: Hi. Thanks for the question. Just want to start with a quick one on iDose. We are roughly halfway through the quarter, and you talked about sequential growth throughout the year and starting in first quarter as well. But fourth quarter had a little bit of one-time dynamics, so it was a little bit weaker than expected. So when we think about sequential growth, what is the right baseline as opposed to using fourth quarter to then grow off of in first quarter? Or is that not the right way to think about

Joseph E. Gilliam: it? I think, Allen Gong, I certainly understand the question. That may be getting a little too precise for what we will cover on a call like this. I think from our standpoint, overall, we gave the guidance that we gave. I gave the color on the first quarter dynamics and that expectation around iDose. I think we have been really pleased with the trending that we have seen so far in the quarter with iDose and the continued expansion thereof. And as you may know and may recall, March tends to be a pretty important month in the first quarter.

And so we still have that in front of us, but we are very pleased with what we have seen so far as it relates to iDose.

Allen Gong: Got it. And then I suppose your installed base, I think we have already gotten a few questions on this, but your installed base of Epioxa O2n is already, it feels like, coming a little bit faster than expected. And there is clearly a lot of excitement and even more durability than Photrexa, and I think us on the Street were expecting. So why would you not be able to convert cases over fairly quickly, like just converting the cases you were doing on Photrexa over to Epioxa fairly quickly once you have that J code?

Joseph E. Gilliam: Yes. I think that is a great question, Allen Gong. So I can confirm that our team has done a terrific job of getting ahead of even what our initial planning was around the installation and the procurement process associated with the O2n system and really establishing the foundation, if you will, from which we can make that happen. The reason why we talk about the guidance in the context of Q2 and Q3 and various things are there, you have to take a step back. First, in the first half, you will have a miscellaneous code. That comes with its own set of unique challenges associated with patient access and working your way through.

The approval processes can be a bit elongated at times when you are using the miscellaneous code. And then once you have the J code established, there are various payer notifications and things that go alongside of that. The combination of those things alongside just the early days of the approval process in any rare disease, let alone, in this case, Epioxa, means that you are going to have a fair amount of patient conversation that translates into, I will call it, warehousing.

It is not really warehousing, but as they are going into the approval processes, we certainly expect those approval processes to be much more elongated as they are trying to go through that because of the miscellaneous code, because of the conversion of J code, because of what you expect in terms of the initial technical denials, and then having to overcome those through appeals and peer-to-peers and all the things that go alongside of that. It just means that you will probably have a bit of a gap, if you will, from when those initial patient conversations happen to where you start to see a, hopefully, more normalized patient pull-through dynamic into treated Epioxa cases.

Operator: Your next question comes from the line of David Joshua Saxon with Needham. Please go ahead.

David Joshua Saxon: Thank you. Good afternoon, everybody. I was hoping maybe we could dive in a little bit more on iDose utilization. I know you have talked about strategically prioritizing iDose standalone cases. But maybe can you give us some flavor on how the different categories of utilization here evolved through the course of 2025, what your expectations are for 2026, and any considerations coming out of the November CAC meeting that are either reflected in your outlook or that may be percolating behind the scenes?

Joseph E. Gilliam: Yes, David Joshua Saxon. You covered a fair amount of ground on that question. So maybe I will start a little bit in reverse as it relates to the CAC meeting and what we do or do not expect there. So far, this process is really aligned with our expectations as the MACs somewhat understandably want to understand iDose TR better, and a goal that hopefully was achieved during the CAC meeting they had late last year. We have not really seen any signs of an LCD. I know there is consideration around that and continue to believe it would be premature at this stage of the launch.

Of course, these things can be unpredictable and sometimes opaque, so it certainly remains possible even if it is not probable at this point. And the guidance that we have given has multiple different directions we can ultimately achieve that.

David Joshua Saxon: As it relates to

Joseph E. Gilliam: where we saw the trending from 2025 and going into 2026, a handful of different spots, starting with the MACs. As you can imagine, we continue to see more growth from the MACs where we have established professional fees. So in that sense, Novitas, Meridian, First Coast,

David Joshua Saxon: we were pleased to see the addition of

Joseph E. Gilliam: NGS to that mix in the latter part of last year, and that certainly contributed as we made our way from the third quarter into the fourth. And continuing into the early part of this year, we see NGS adding benefits.

David Joshua Saxon: We have continued to see

Joseph E. Gilliam: the relative percentage of procedures done where physicians are treating glaucoma at the same time as a cataract procedure

David Joshua Saxon: increasing.

Joseph E. Gilliam: That was expected given we have already changed the standard of care for those patients over a prolonged period of time.

David Joshua Saxon: And as we enter into 2026,

Joseph E. Gilliam: I think the expectation should be going back to those same things: that we knock down the remaining MACs. At this point, I can confidently say that we are the closest with Palmetto. I think we are on the doorstep there and hope to see that in the coming days, if not weeks. And we certainly are making a lot of progress since the beginning of the year with them as well as with WPS and CGS. And then I think I have mentioned this before, but the other big initiative for us in 2026 is really focused on driving increasing utilization in that broader patient population that is also represented by commercially covered lives as well as Medicare Advantage.

David Joshua Saxon: That is very helpful. And then maybe just a follow-up as you think about the shape of 2026. I know a few others have asked this, but you went down the path of introducing 2026 guidance earlier than you normally do in November, and I think that was probably in anticipation of how we might perceive the pricing impact in Epioxa and trying to keep numbers at a reasonable place. But maybe you could just help us think about when you introduced that guidance to now and as you sit here a few months later, what, if anything, has changed?

And where do you have more confidence, or where do you see risk that you want to make sure we reflect in the outlook?

Thomas William Burns: Yes. I think it is a great question. I mean, first,

Joseph E. Gilliam: we introduced it, you are correct. With the pronounced change in how we thought about both the pricing dynamics as well as all the considerations around the market access element of the transition from Photrexa to Epioxa, we did want to make sure that folks did not mistranslate that and get ahead of us in the context of the way we think it will actually play out on the ground as we make our way through 2026. Since that time, pretty much across the board, things have probably played out somewhat favorably. But if you could imagine, even inherent in the question, a lot of the things that we are talking about are

Ryan Benjamin Zimmerman: later in 2026. And so

Joseph E. Gilliam: whether it is the continued sequential growth and getting a feel for how that continues to play out in iDose TR, or we have talked a fair amount about the Epioxa dynamics, which are really largely weighted towards the second half and even the fourth quarter, it was premature, despite the positive underlying fundamentals of the site-of-care network for Epioxa or the payer progress or even the trends that we have been seeing with iDose, I think, to make any adjustments to our guidance at this early stage.

David Joshua Saxon: Very helpful. Thanks for taking the multipart questions.

Thomas William Burns: They did. Big

Operator: Next question comes from the line of Richard Samuel Newitter with Truist. Please go ahead.

Richard Samuel Newitter: Hi. Thanks for taking the questions. Two for me.

Joseph E. Gilliam: I am just curious, are you factoring in readministration at all in the sequential improvement in the color that you gave on U.S. glaucoma? We can all back into the iDose number; it sounds like you are pretty comfortable with where the consensus is based on your comments. So that is the first question. What, if anything,

Allen Gong: readministration as you can factor it in there? I will just ask my second one. When you talk about

Joseph E. Gilliam: co-pay assistance or market access programs that you are investing in, can you elaborate a little bit more on what exactly you are doing with the specialty pharmacy access to make adoption more fluid

Allen Gong: for payers and patients or providers and patients, and are you also talking about your ability to move things through the denial process?

Richard Samuel Newitter: Does that denial process go away once

Joseph E. Gilliam: you have the J code in place now it is a drug? Thanks. Sure, Richard Samuel Newitter. I think I took all that down, but if I missed something, you can circle back. I think it is fair to say that readministration

Richard Samuel Newitter: was not a material consideration as we thought about the guidance. Certainly, as we set it back

Joseph E. Gilliam: in November and then, as we have affirmed it here, we sit here today, given my earlier comments, we would expect there to be some readministrations as we make our way through the year and some of those very early patients get into the window of where readministration becomes a viable option. I think readministration becomes a much more material contributor to how we think about the business in 2027, 2028, and beyond. It is something that we are thinking about in 2026.

And, inherent in your question, then from an iDose standpoint, I will say it again: there are multiple different directions for us to try to achieve the numbers we put out, and in the context of both the existing MACs where we have got professional fees established today, the incremental professional fees that we expect to have on schedule, if you will, from the remaining three MACs that represent another 30% of the covered lives out there, or our initiatives that we are certainly investing a whole lot more in on the commercial and Medicare Advantage side.

Each of those, I think, drives the confidence in the commentary both around the overall guidance as well as the sequential improvement that we expect. Now on Epioxa, and I will call it the investments we are making both to drive or optimize patient access as well as turnaround time, I guess the best way you can say it, on some of the support elements is there are always, from a service provider standpoint, good-better-best type programs. And when you launch a rare disease,

Allen Gong: you clearly have to invest in, quote-unquote, the best.

Joseph E. Gilliam: The best from a hub standpoint, the best level of service from a specialty pharmacy standpoint, incentivize maximizing access and driving the most experienced professionals within those organizations, and the turnaround times associated with them. I think we have been on record as saying from a co-pay assistance that we will have a $0 co-pay program for commercially covered lives that you hope that in the vast majority of cases,

Allen Gong: patients can qualify for that

Joseph E. Gilliam: to make sure that is not an impediment to access. And, again, really all of these things, as well as our broader efforts that we will have on DTC, provider and patient education, are all meant to be a substantial increase in the investment we are making to drive the awareness and the detection and then ultimately the treatment turnaround time for those patients who are afflicted with this disease.

Operator: Your next question comes from the line of Mason Owen Carrico with Stephens. Please go ahead.

Mason Owen Carrico: Hey, guys.

Joseph E. Gilliam: Thanks for the questions. Could you quantify the number of sites that have received the equipment to perform Epioxa procedures or the numbers that have committed to it? I know that you called out the O2n system had been deployed to locations covering something like 40% of the population, but should we be interpreting that as a single Epioxa site now covering a much larger geographic area than the average Photrexa site?

Thomas William Burns: Yes. I mean, I think I will probably stop short of giving specific numbers around the site-of-care and the various things and simply say that when you look at it, to your example, if you have a site within the Atlanta metro area, for example, that is designed to cover that patient population. And that is not uncommon. So when you think about the launch, you want to make sure that you have got the providers who are the best at going through the process we are about to, that are committed to the care, and are willing to go through the payer hurdles, if you will, and make sure that they are being properly educated.

So you focus your efforts on those while trying to make sure that you have got the geographic reach that you need. And then over time, you start to supplement that to make sure, again, that patients do not have to wait an unnecessarily long period of time to get access to care. So I would expect that, and we are happy with where we are at for the initial launch. The wave-one customers, you heard Thomas William Burns reference earlier, are wave one for a reason.

Mason Owen Carrico: And then, ultimately, over the

Joseph E. Gilliam: coming months, quarters, and years, we will continue to expand that network out and offer more and more sites within a particular geography to make sure that we are getting access to those patients.

Mason Owen Carrico: Got it.

Joseph E. Gilliam: And then on the coverage front, I think you said you are in conversations with four of the five top commercial payers. Do you believe that you could realistically have a positive coverage decision from one or more of those in 2026? Do you have an internal target for the number of covered lives that you could have by year-end?

Mason Owen Carrico: Yeah. You know, Mason Owen Carrico, I think I would take a step back to what I was saying earlier, and we will see whether or not we have a positive coverage determination/policy

Joseph E. Gilliam: and the variety of other things that help expedite patient access in 2026, whether it is with those top payers or others that are out there. The thing that we are watching most closely as we launch is that patients are able to work their way through the approval process, the prior authorization process, with each of these payers and the broader network of payers that are out there

Adam Carl Maeder: such that we are able to confidently believe that we have got

Allen Gong: access,

Joseph E. Gilliam: a pathway, for the vast, vast majority of patients. That is the initial goal. From there, you start to focus more and more on optimization, whether or not they are getting that access through the pharmacy benefit or the medical benefit, whether they are getting that on the initial prior authorization or through the appeal process, and ultimately whether or not achieving that access through an established positive policy that provides the cleanest and clearest pathway for them to get access to the drug. Got it. Alright. Thanks.

Thomas William Burns: Thanks, Mason Owen Carrico. Thanks.

Operator: Your next question comes from the line of David Joshua Saxon with Needham. Please go ahead.

David Joshua Saxon: Great. Thanks, and good afternoon. Maybe two on the glaucoma business. First, on iDose, you talked about commercial cases. So what are you hearing in terms of doctors starting to really get into that patient population? I mean, is it more of a trickle, or are you seeing that build? And then the second question is just on the iStent franchise. You talked about flat growth expectations for the year. Is that just because of how you are incentivizing the reps? Obviously, iDose is the focus right now. But

Joseph E. Gilliam: what is the view there? Is that more of a market dynamic or anything around competitive dynamics? Thanks so much.

David Joshua Saxon: Yes, David Joshua Saxon. I think so first,

Joseph E. Gilliam: as it relates to the commercial, and I lump them in with Medicare Advantage because those are shepherded by commercial carriers, I think it is very provider-specific. So in those geographies where we have had the proper Medicare fee-for-service coverage for a while, we are starting to see providers turn on where they are offering it to a wider swath of patients. And for those that are good at it, we are seeing them do that in a more fulsome way. Our efforts in 2026 are to really try to expand that in a much more significant and profound way as we make our way through the year. I think about it in three pillars.

We have been talking a fair amount about payer access on the Epioxa side. It is obviously relevant on the iDose side as well. The good news is our foundation here is pretty strong. We have seen successful authorizations for therapy and the payment of both the J and the T code from payers that cover the majority of patient lives, including four of the five, in that case as well, largest payers on the Medicare Advantage side. So I think we have got a pretty solid foundation to expand in terms of the payer side. The second is process optimization.

It is going to again sound fairly familiar with what we are talking about with Epioxa, but it is driving the entire ecosystem from our iDose hub, our iDose SP providers,

David Joshua Saxon: to the payers and accounts themselves to reduce the barriers and

Joseph E. Gilliam: increase the patient access and optimize the treatment for patients on that side of the house. And then the last thing, which we have not talked about in a while, is the patient economics. Similarly, we have established programs to support commercially insured patients where most of them should pay as little as $0 out-of-pocket. And then for MA patients, I think from the very early days of the launch, we have said that the data suggests that about 20% of those patients have no to low out-of-pockets in terms of plan designs, and then access tends to increase from there throughout the year as patients meet those out-of-pocket requirements on other procedures.

David Joshua Saxon: So I think we are still in the early innings.

Joseph E. Gilliam: But we are seeing, obviously, encouraging signs on a provider-by-provider basis that we hope to expand as we make our way through 2026. As it relates to the iStent franchise, it is interesting. Implied when you go back and do the work on the fourth quarter results, you will probably see or have seen that we were back into the growth equation for our non-iDose portion of our U.S. glaucoma business. And we talked about the trending heading this direction before, and so we were encouraged by the fourth quarter in that regard.

David Joshua Saxon: But I think it is a little too early to call it a trend.

Joseph E. Gilliam: And it is, in large part, about the first part of how you asked the question, which is yes, there is a lot of rep incentive and focus and company incentive and focus around interventional glaucoma and iDose in particular. And so we will have to see a couple more quarters to determine whether what we saw in the fourth quarter was a trend or an anomaly as it relates to that. And as a result, I think we have said for a little while now, it is safer to just assume that the iStent or broader non-iDose franchise remains flat on a year-over-year basis when assessing our 2026 guidance.

David Joshua Saxon: Great. Thanks so much, Joseph E. Gilliam.

Operator: Your next question comes from the line of Danielle Joy Antalffy with UBS. Please go ahead. Danielle Joy Antalffy, your line is open. Oh, sorry about that. Thanks so much for taking the question. Good afternoon, guys.

Danielle Joy Antalffy: Forgot how to use the mute button. To follow up on some of the questions around iDose and standalone use, I am just curious, if you look at the business as a whole—so iDose plus iStent Infinite—what are you seeing there as far as the shift to standalone use? And at a higher level, maybe talk about some of the market development lift that is necessary to really build that market. And what you are seeing—I know it is early days—but I was at AAO, and I felt like there was a big focus on this. So I am just curious what you can say there. I will keep it to one. Thanks.

Joseph E. Gilliam: Yes. Thanks, Danielle Joy Antalffy. I am glad you were at AAO and you were able to witness that, and I think you will continue to see more and more of that, whether it is at the upcoming AGS meeting here later this week or ASCRS a short while later. I will probably start in reverse that it is a significant investment. We have been at this since the approval of iDose, really, in making that happen. It is not our first time going through transforming a marketplace. Obviously, we did it successfully over the course of the last decade for those patients that were faced with the disease in combination with cataract surgery.

And it really is a combination of incentive for your salesforce alongside the marketing efforts that we are making, the medical affairs efforts that we are making, the publications, and the like. And when you put all that together and really build upon, I think, the enthusiasm that surgeons have out there for a disease that they know is interventional, is asymptomatic and slowly progressing, and there is a really large patient population in need for a variety of reasons, it is about being on that journey on a consistent basis at industry conferences and all the moments in between that we engage with those surgeons.

And really changing the actual practice dynamics and shifting towards the standalone treatment of these patients and aligning both the behaviors at the practice level and the clinical belief that exists in the vast majority of the physicians that I am sure you are speaking to or have spoken with in the past. And when you put all that together, we continue to see substantial growth from standalone procedures.

Whether that be 20 million eyes, 12 million of which are actively diagnosed and treated, and so you probably heard us say—and certainly Thomas William Burns say—at other conferences and the like that over time, we expect that the number of glaucoma procedures done in the United States will exceed the number of cataract surgery patients that are treated. It will take time, but that is our ultimate focus and the reason why we are making such a substantial investment to the benefit of those patients.

Danielle Joy Antalffy: Thank you so much.

Operator: Your next question comes from the line of Joanne Karen Wuensch with Citi. Please go ahead. Good evening. Thank you for taking the question. I have so many. In no order. Are you seeing physicians creating a waitlist for Epioxa? Would that imply a stronger second half once the J code is applied or put into place versus the first half? Could you see 2027 faster than 2026? And if I do my math correctly, iDose guidance is $225 million for the year. What makes that the right number? And thank you.

Joseph E. Gilliam: Do you mind repeating that? You cut out a little bit of the 2027 versus 2026 part of your question?

Operator: Do you think revenue in 2027 growth rate will be faster than 2026 given the momentum of Epioxa?

Joseph E. Gilliam: Okay. I will try to go through those in the order you asked them. So from an Epioxa perspective, we are starting to see, and we will give you the example, we certainly are seeing patients be enrolled in our hub

Joseph E. Gilliam: for approval to Epioxa. So inherent in that means that a “waitlist” is being created. I do not know that it is enough to obviously impact our first quarter. I think there will still be enough of Photrexa there, as I said earlier, to drive year-over-year growth. But we do expect that waitlisting dynamic to be much more material in the second quarter to the detriment of that for the cornea business and probably the benefit of the latter part of the year, certainly the fourth quarter, perhaps even tail into the third quarter as those patients start to get approvals and access to therapy and are ultimately treated.

So we absolutely expect the second half to be the key contributor to those results. And as we learn more about that, we will obviously dial in our expectations in a much more meaningful way. As we think about 2027 versus 2026, I probably will stop short of giving, at this stage, 2027 guidance implied by the comment. But, clearly, you have heard from us that the combination—the one-two, if you will—of continued acceleration with iDose alongside what we hope will be a meaningful acceleration with Epioxa makes not just 2026 an attractive year, but

Anthony Charles Petrone: 2027 and beyond if we look out

Joseph E. Gilliam: and think about what it could do in terms of driving our business and the topline associated with it. I think your last comment was the implied, and we did not give the exact number, but you get into the numbers, I think there will be a range of estimates that come in that general ZIP code. And what makes it the right number? We are always at a bell curve of scenarios, the various puts and takes within these, and trying to establish guidance both on a macro level as well as on a more micro level that we think is achievable for us. And in this case, as I have said previously,

Adam Carl Maeder: I think we have got multiple pathways to both grow

Joseph E. Gilliam: and continue to grow sequentially, as well as achieve that. And as we make our way through the year, we will continue to update those views and

Michael Anthony Sarcone: provide them as we go forward here.

Operator: Thank you so much, and thank you for taking my multipart question.

Joseph E. Gilliam: Yes. Enjoy, Joanne Karen Wuensch.

Operator: Your next question comes from the line of Steven Lichtman with William Blair. Please go ahead.

Thomas M. Stephan: Thanks. Evening, guys.

Thomas M. Stephan: Question on iDose. Can you give us a sense of how many surgeons you trained last year and to date? Or even qualitatively, can you talk about where you are in that process? So still early to mid-innings? Any color on that would be helpful.

Joseph E. Gilliam: Yes, Steven Lichtman. Well, to William Blair, and I think from a surgeon training perspective, it has not really been a focus for us in terms of what we communicate to the Street, and that is by intention. That is really not the, I will call it, gating or limiting item for us. Our surgeon training activities have been as strong as they have ever been. The vast majority of these surgeons have already been angle-trained over the course of the last ten years of utilizing MIGS technology. So from a sustained pharmaceutical standpoint, we are good there, and it has really not been the step function that is driving where we are at.

I think broader office administrative-related considerations, reimbursement confidence, professional fee, and then, as we move forward here, bringing commercial Medicare Advantage online are much more key drivers to where we are at and where we are going. But so far, we have been pleased with the pace and the overall ability for our salesforce to train these doctors in the OR and get them comfortable with the iDose procedure. That makes sense. And then just secondly, I want to actually ask about international glaucoma. It came in

Gursimran Kaur: above initial expectations last year.

Gursimran Kaur: Despite competitive dynamics you flagged going into

Gursimran Kaur: 2025, do you think there was a delay in some of the competitive headwinds that we could see this year, and that is what is embedded in your thoughts? Or just staying on the conservative side? Because it would seem like Infinite could be a nice catalyst there. Thanks.

Joseph E. Gilliam: Yes. And I think it is a balance, and we will see how it plays out through 2026. You have competitive interests, particularly in some of our larger markets. In 2025, it did go a little bit more slowly than maybe we anticipated or certainly built into our forecast, and that is a credit to our teams that operate in those markets and the relationships they have built and the differentiated positioning of our technologies.

As we move forward, we do expect those efforts to continue to accelerate, but to your point, they are also balanced against our launch and launching of iStent Infinite throughout the European region, some of the affiliated markets that follow European approvals or clearances, as well as continued blocking and tackling that we have around opening up markets or markets within markets, and that journey never stops. So I think as we make our way through here, it will be that interplay. You are right.

And coming off of constant currency growth in the fourth quarter of 13%, as you heard me say earlier, we expect high-single-digit to low-double-digit in the first part of the year, ultimately abating to something a little bit slower in the second half to be in the high-single-digit range for the year. I think that is a good place for us to start off the year as it relates to our guidance for that part of our business.

Gursimran Kaur: Makes sense. Thank you.

Operator: That concludes our question-and-answer session. I will now turn the call back over to the company for closing remarks.

Thomas William Burns: Okay. I want to thank you all for your time and attention today. And thanks again for your continued interest and support of Glaukos Corporation. Goodbye.

Operator: Ladies and gentlemen, this concludes today’s call. Thank you all for joining. You may now disconnect.

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