RxSight, Inc. (RXST) Earnings Call Transcript & Summary

My name is Craig Bijou, one of the medtech analysts here at BofA, and it's a pleasure to have RxSight here with us today, Ron Kurtz from the company, CEO; and Shelley Thunen, CFO. So Ron, Shelley, thank you for being here.

Thank you for having us.

So I want to start with Q1 results. You ended up -- you preannounced Q1 revenue that grew 28% year-over-year, but it missed TheStreet. LALs missed, but LDDs beat. And I think you called out some macro impact on LAL sales. So maybe if we could just start there and you guys can just kind of walk through what you saw in the quarter.

Why don't you go ahead and start, Ron, because start at the macro end and I can talk specifically.

Yes. I mean, just broadly, of course, we all live through this, but the -- what we saw was -- typically, we'll say that our demographic, the over 60 population that's getting cataract surgery is relatively resistant to macro headwinds, and that's true. It's been true really since the premium market was established. But those typically are your signs of recession or inflation where this demographic is more resistant to those things. What we saw in Q1 was a little different than that, where it was really some shocks to the equity market with significant reductions in the major indices, which does impact our demographic. And combined with that, there was obviously a change in administration with a very different approach that led to what we would say is a reaction from the older demographic, which I'm part of. And there, when we surveyed our customers, those effects were cited most commonly as the reason for patients either deferring treatments or even canceling surgeries, which we haven't seen since COVID really as well as trade downs, which would be another impact of kind of a negative wealth effect.

And I guess so I do -- so Alcon reported this morning and talked about a softer premium IOL market. They -- I mean, they talked about -- they actually talked about productivity of some of their docs and the change with some of the higher volume docs maybe either doing less or maybe not retiring. And -- but it does -- I guess I want to ask you guys if that's something that you've seen or if the dynamic that you guys experienced or saw is something different than that?

Well, I certainly wouldn't argue with that effect, but that's not a new effect. That's been going on for a decade or longer. It's really a generational change that is going on in ophthalmology and all of medicine and probably in all of our society is there's more of an emphasis on work-life balance. And private equity accentuates that in that the incentive of the physician owner or the practice naturally drops, although it's still -- they try to maintain that through the incentive structures. But I don't think that, that's any more in Q1 than any other time. So I wouldn't disagree with the calling out that as a factor that's going on in the marketplace. But I think that what we saw in Q1 and is more directly tied to the more immediate effects or the shocks to the system. I think that we may be -- a couple of factors are a little bit different between what we experienced and what they experienced. If you go back into 2024, the overall market -- and actually, if you go back several years, the overall premium market has been flat to dropping actually in the second half of 2024 if you take us out of the equation. And the growth that has gone on, especially in the last several years has been due to the LAL. So I think that's a little bit of different dynamic than probably what they experienced.

Got it. And I do -- I guess -- and I don't know if this is for you, Shelley or Ron, LDDs came in better than expected in the quarter. So it's not necessarily a capital equipment issue or selling that, which I know a lot of investors are concerned about. So maybe just from the LDD placement or sale perspective, what did you see in Q1 from that perspective because that was obviously strong.

Yes. And we had strength in LDD sales throughout all of '24 as well strong in the first half of '24 and the second half of '24, and that continued in. But I don't think that when we look at capital equipment sales, that is a longer-term look at the business that the practice and if they're owned by a PE looks at. So there are 2 things about it. One, with the LAL, they offer twice as good results for the premium patients as they would get with the monofocal and Ron can talk about some of those studies as well as our own data. So they want to offer something better for their patient. And number 2, they make more money, right? Because they draw about 75% of the patients from a much lower, as Ron said, from about 40%, 45% from somebody who would otherwise get monofocal or another 30% or 35% from somebody who will get a toric, which is less than half of a premium IOL and then the balance around 25% from other AT-IOLs. So they have an opportunity to make about $2,000 per eye and payback of about 6 months, but it does require that they make some change in the practice flow. They need to learn about a new technology, a new IOL. They haven't done adjustments before. And so we come in and help them do that, teach them how, but they have to be ready to make that change as well within the practice. So that's more of a long-term look at the practice and what they need to do to grow. And I think that's important about the capital equipment. Ron, would you add anything to that?

The only thing I would add is going back to your first question, I think that the fact that we do draw a lot of our patients from the monofocal and the lower-priced toric could make us a little bit more sensitive to trade downs. And we did see a little of that in some of the surveys that have come back as well as our own. So that's on the good side, it grows the practice. On the bad side, it makes it a little bit more sense.

And I guess on that point, that was one of the questions that I had. So if a patient is potentially worried about spending money. So toric IOLs would be less expensive than LALs, right? And then monofocal obviously, would be even that much. And you did see some of the surveys show that some people chose to go with monofocal and LAL and -- or toric instead of an LAL? Or I guess, what did the survey tell you from that perspective?

So we weren't that specific, but in the -- in some of the notes that was noted, and it was also noted in some of the external surveys. But it's -- I think that the other fact that sort of supports that is that overall cataract surgery was also down. And so that you would say, well, gee, why is that? But a large -- for the 80% of the people who are getting monofocal cataracts, a fairly good segment of those are modest income people, and they're paying $400 in a copay. So even with Medicare. So there's -- so they may be even more sensitive to -- and that may be reflected in the overall cataract market.

Got it. Maybe switching back to kind of expectations for Q2 '25. I know you don't guide quarterly. So I'm just going to give you some of TheStreet numbers what TheStreet is expecting. So TheStreet has you had total revenue of $39.8 million. And I think it's flat LDD revenue and placement and then assumes 20% LAL growth. I mean, I guess your reaction to that or any directional feedback on how TheStreet is modeling Q2?

I would think that what we said about Q2, and I think TheStreet took some information from us is one that is typically a very strong quarter, but we look at it as being more informative to 2025 than a specific guidance as to what is normally what we see in seasonality. I think the other thing that we did say is that Q1 was affected by timing to some degree. Typically, in Q1, what we see is 40% to 45% of the LAL unit sales and dollars are -- it come from March, right? And so you see that uptick in March starting into that strong second quarter. What we saw in the first quarter was it was more like 1/3, 1/3, 1/3, right? It wasn't quite that. It was a little bit more. But that was unusual. And while we had terrific growth, it still was not quite what TheStreet numbers were. And what we did say also is that we saw an improvement in April, but it was higher than March. But we still think that Q2 could be instructive for how the year would come out and not any differently than Alcon, we would expect that the growth would happen in the second half of the year. And that's really based upon the supposition that economically, things would calm down, right? And that would help consumers get their confidence back.

Got it. And if we look at the guidance, so I know you expect it to accelerate throughout the year or to get better throughout the year. It's a pretty wide range for the full year 2025. So it sounded like the lower end of the range would be that you wouldn't see much of a pickup in the second half. And I guess, is that the right way to think about how you've set up the guidance for the year?

Yes. As we looked at the guidance, of course, Q1 was quite unusual. But of course, the environment was quite unusual, a shock to the system is at the low end of the guidance, what we're assuming is that existing customers would be about what they were in the first quarter, right? And that our growth in LALs would come from the customers that were installed in the second half of '24 because they're just getting going as well as new customers signed in 2025. We also assume that we would sell more LALs than we did in 2024. As you move up into mid of the guidance and the top end of the guidance, we're talking about that reacceleration in the second half of the year. And that would be a function of how much we would get as well, but we do think we will get some reacceleration in the second half of the year.

Got it. And following up on your comment on the LDDs that you expect to sell more LDDs in '25 versus '24. I think you were 7 higher. Actually, you were 7 higher in Q1 than you were prior year Q1.

Yes.

So what -- I guess, just maybe a clarification. When you say more, do you mean more for the rest of the year, like the last 3 quarters or the entire year?

Yes, I'm glad you made that distinction. Everything is important in words, but we meant for the entire year.

Okay. All right. And then -- and we've talked about this on -- you're still confident in the LDD selling a lot of LDDs, and you don't think the LAL, call it, hiccup or market reaction or maybe hesitancy of patients would impact any LDD sales. So maybe just, I guess, your confidence that the consumer or not willing to spend on LALs early on won't have some kind of impact or negative impact on LDD sales later on for a practice.

Well, I think it depends on what happens at the consumer level. Obviously, if that's a prolonged thing, then eventually that can. But the basic situation is that doctors and practices are faced with continuing reductions in reimbursed services. And that's only going to accelerate with the current budget proposals that are out there. And so they're looking for ways to deliver high-margin revenue. And there are very few ways to do that other than premium IOLs. And as I said earlier, if you look at the growth of premium IOLs in the last few years, it's been the growth of LAL. So if I'm in a practice and I want a -- or a PE owner and I want to grow high-margin revenue, I would hope that they would look at the light adjustable lens as their first opportunity to do that. And I -- as we talked about earlier, we think that a lot of these macro effects are hopefully transitory and that as those -- that becomes apparent, that won't impact LDDs.

Got it. One more clarification, Shelley, on -- before moving on to other questions. So the LDD placements -- how -- what are you expecting international contribution to LDDs?

Yes. They will be a portion of how we increase our number of LDD sales. But as we've said overall, both for LDD as well as LAL, 2025 is pretty modest, right, in terms of that. And that's really just paced by the approvals, right? We just got Korea, we just got EU. We expect U.K. sometime this quarter. So those are very recent for us. And this year would be more about seeding the market rather than a big '26, '27 would be when we would see more impact.

You did also announce workload challenges and investment or more of a focus on education and marketing and support for the practices. So -- and I guess first question is, is that separate from the market maybe or the hesitancy of patients to get an LAL? So are those 2 or your decision to do that, is that separate from -- or is it in a reaction to some of the hesitancy that you saw?

I wouldn't say it's -- I don't think it's directly related, but since we went out and surveyed our customers after Q1, we got additional feedback, which led us to that conclusion as well. And it's not as though that's unexpected. I mean, if you think about it, we introduced a new way to do cataract surgery, certainly postoperative care 4 years ago. We have installed over 1,000 systems, and we've certainly learned a lot about both how practices can optimize the implementation of our technology as well as just clinical pearls. There are basic things that were -- people did not do refractions, serial refractions after cataract surgery. How do you evaluate a refraction after cataract surgery to know that, that's to base a refractive treatment on? How do you -- when a patient didn't have a choice in what their refractive outcome was going to be, they got what they got. And if they didn't like it, you could maybe do a secondary procedure on them. Now they have a really meaningful input in that. Well, how do you guide that input? So there's a lot of information that we've gleaned over the last 4 years. And this is a good time for us to go back and disseminate that information in a more systematic way to all of our customers, but in particular, to those customers that have saw some changes in their volumes.

And I guess some of these programs, are they directed -- you said it's based on feedback that you've gotten with some of the outreach that you've done. Are they directed at some of the lower volume or lower utilized LDDs or is it more of a broader base? And I guess the question is, are there efforts, one, like did you hear from the physicians that we need this or we need some other -- we need a way to unlock more utilization or to get -- we need this before it's a higher percentage of the -- before LALs are a higher percentage of the procedures that we do. So is that kind of the genesis of it where you can really unlock and maybe get deeper within the practices?

I wouldn't say it was a direct link that they identified. They identified things that they would like to have more education on and more assistance with. We assume that, that's going to also deliver higher volumes of procedures. And so obviously, when we have 1,000 customers, we have to prioritize where we're going, and we prioritize where we think we can have the biggest impact on the largest number of procedures. But ultimately, this information that's going to be helpful to everybody.

Got it. Okay. If we can just talk a little bit about utilization. I think, Shelley, you've made some comments about the cohort in '24, maybe not having the same ramp in utilization as prior years. I know you were impacted, Q1 procedures were impacted, but the LDD base installed base grew more than LAL procedures. So maybe just talk about kind of what you're seeing from a per practice utilization and why '24 may have been a little bit down versus the ramp that you saw in prior years?

Yes. No. And I think that as we look at our cohorts, each of which are pretty small, let's be honest about that. We look at '21 in prior installs, '22 as a cohort and '23 as a cohort. And what we see in those cohorts is; one, on '23, they grew faster to get to the same place than the previous cohorts, which kind of makes sense to us as well. And they all seem to move and be almost the exact same number of LALs per LDD. And until we had this Q1 when we were down as to the number of LALs per LDD, they all continue to grow and get to about the same level. Looking at '24, it's still a little early because it takes about a year for a customer to get where I would call mature, but not necessarily as high as we would like them to move. So I did look at the first half of '24 installs. And what I said is that they're not growing as quickly as the cohort in 2023. So it may be somewhat of the fact that, again, you saw some of this macro effect, not the shock to the system, but a slowdown in growth and actually negative growth in other places, except for us, that they're just not growing as quickly. I think as we get toward the end of the year, I'll have more in the cohort and know a little bit more about what they're doing. And of course, from a sales force viewpoint, we manage the company from the bottom up. Everybody in sales and even our clinical people have accounts that they're responsible for. And so they're responsible for ensuring that they get the information, the training. And of course, we have rollout of another piece of software, software upgrade that we just talked about on the call. They're also responsible for looking at volume and asking customers what we can do. So that's a very bottoms-up effort. The cohorts are mostly just to tell me if everybody is growing and if we're getting kind of the same linear type of look at the business.

And I'm jumping around a little bit, but I kind of want to go back to the notion or that docs might be retiring or lowering their volume. And the docs that adopt your technology, where are they in their careers? So are they a few years of experience? Are they more experienced? Is there a range? Or do you see any disproportionate? They're early docs and they see your technology as maybe a way to make a name for themselves?

I don't see our range of doctors are very similar to the range of doctors that are -- I don't think we've penetrated any one demographic of doctors more than anybody else. And that makes sense in the sense that doctors practice in groups generally, and there's a wide variety of people in the groups. I do think that our technology -- any new technology is going to appeal to the doctors who are further away from retirement just because it's a natural inclination that the more senior you are, the less inclined you are to do something new. And also, conversely, the younger you are, the more likely you're looking for a way to distinguish yourself. And I often advise younger physicians that when you have technology or paradigm shifts in technology, that is a great way for you to advance your career because nobody is an expert in it. And so you can become the expert in it. And we certainly see that. But we also see some of our best customers are senior doctors who know that paradigm very well as well. And so they don't want to get left behind the curve. And they -- and so they also have moved forward. But I do think that to the extent that technology is a comfort to patients that it's the technology that is delivering the clinical result, it makes patients more likely or less likely to emphasize either the bravado or the experience of the surgeons. So I think it does work in -- that process works in our favor, but it's a small effect.

Okay. Only a couple of minutes left. Maybe just touch on, Shelley, you brought up the international approvals that you guys have gotten recently. It sounds like the international premium IOL market is actually doing extremely well. So just talk about kind of your opportunity launch there and kind of what investors should think about your ability to penetrate these markets?

Yes. I mean, obviously, we like that the international market continues to get more attractive as we approach it. It's a fairly focused market or opportunity. There are about 20 individual countries that do 80% of the OUS volume in premium. And there's us -- we are focused on those and actually a somewhat smaller subset where pricing is very similar to the U.S. So we're -- they're the major countries of Europe and Asia. Obviously, we've gotten our initial approvals and are going to be focused on building our key opinion leaders, clinical experience, clinical data in the market because people like to see that, hey -- they understand that the technology has had a lot of success in the U.S. That's a big plus. It's a -- the fact that it's been approved by FDA, that we've been out in the marketplace for several years. There's a -- that's a big endorsement, but they still want to have local validation. And so that will be our focus, building data sets in country where we can do that before approvals, we will do that. But usually, it requires you to have the approval and start to build up that. And that will be our emphasis in '25.

Got it. And modest contribution, I think, is the words that you used. I mean, any directional color on that?

I would just say modest overall. I mean, we've got a nice installed base here in the U.S. And that's where we'll have the vast majority of our LDD sales as we've had in previous years as well as the installed base really is where you get most of your IOL sales, the LAL.

We're just about out of time, so I probably don't have the time for another question, but I want to thank you, Ron and Shelley, for participating.

Thank you very much. Good. Thank you.