The best bit, disclaimers. Multistudy.com/research-disclosures. It's a very exciting website, so I recommend everybody goes there. What is good fun is having the Sight team. Massive thanks to Paul and Ali, our CEO and CFO respectively, for joining. Thanks for coming. Thanks for having us. Why don't we start about quite big picture, the MIGS market overall? I guess interventional glaucoma, there's been a lot of noise around the LCD and payment changes and things like that. What's your vision for how you think this market as a steady state midterm can grow at and look like? I'll start off, and Ali, you want to follow on? Generally, you know, look, glaucoma remains a very serious problem in eye care. Glaucoma is the world's leading cause of irreversible blindness. Patients need more interventional, minimally invasive or less invasive options to control the disease. MIGS has done, it's made great progress in terms of improving clinical outcomes for patients. There's a number of interventional approaches beyond MIGS that are very exciting. While there's a headwind this year with the LCDs, we think that headwind will lap in Q4. Patient visits continue growing. We expect the MIGS market to return to growth in 2026. We're proud of how we've been performing in that market despite the headwind. I think our commercial team has done a nice job. We're focused on making sure that we're in the best position possible at the end of this year so that when the MIGS market does return to growth, we're in a strong position to capture as much of that growth as possible. It's an exciting category. You know, there's a headwind this year, but generally as a category, it's a serious disease. It's a growing problem. It will continue to be a serious disease, and patients will continue to need better and better options to allow eye care providers to intervene earlier. We're happy to be playing a very meaningful role in the minimally invasive or interventional glaucoma market. That's with OMNI today. We have SION as well, and we have a number of exciting pipeline projects that we're working on also. For people who are maybe less familiar with glaucoma, there's a lot that goes into it, right? Illness, you know, you have like hypertensivity, you know, diabetes, aging. There's a lot of structural drivers. Is there any way we shouldn't expect to see rates of glaucoma in totality in pretty much every market just growing pretty consistently? I mean, unfortunately, we expect it to continue to be a highly prevalent, problematic disease. Now, again, what can we do about that? We can continue to innovate and develop better and better technologies, less invasive approaches that are as effective or more effective than the invasive alternatives. Ultimately, if we can do that well as an industry, obviously we want to do it better than anyone else here at Sight Sciences. If we can keep doing that, we'll continue improving care for patients. That's ultimately what this is all about. Sometimes glaucoma reminds me also of hypertensivity in that there's a bunch of different technologies, but we have to throw all of them at the patient because a lot of the time it's either progressive or the compliance is bad, or frankly you need a whole range of technologies simultaneously to really get the IOP down and to manage the patient. From your perspective, we've got things like laser, we've got things like MIGS itself, drops. If you cast your mind forward, do you think we're always going to need all of those tools or do you think there might be a stage where one of them gets good enough to manage the disease on its own or we're just going to never? I think over time we should have leading interventional approaches for every single patient. Instead of topical eye drops for that patient that first presents with high pressure, where you don't necessarily want to go straight to surgery, it should be an interventional means of delivery of medications as opposed to relying on the patient with daily compliance and ocular surface issues. I think over time we will have several best-in-class sustained release interventions. We will have a higher utilization of SLT laser as an early intervention. We will have a broader array of MIGS approaches that match the disease severity or the patient. Hopefully, we'll have more efficacious but less invasive end-stage alternatives. I think the future of glaucoma treatment is bright for eye care providers. I do think it will look more and more interventional over time. How do you, sort of last one of the big patient market, how do you think about the patient journey and the, you know, a chunk of these patients are often type 2 diabetic, it's often an asymptomatic condition. Compliance with drops is not always great. How do you think they enter the more active interventional funnel, if you like? Is it loved ones sort of kicking them to do it? Is there a sort of moment where they have to realize it? How do you feel like the patients come to you? Yeah, I think what drives a lot of it is the patients trust their doctors. Obviously, family relationships have an influence, but the doctor-patient relationship, certainly in ophthalmology, I think in most areas of medicine, but certainly in ophthalmology, is a very strong one. Patients do tend to listen to their doctor's recommendations. I think from our perspective, from industry's perspective, we need to continue educating our surgeon customers that earlier intervention is better. We need to continue generating clinical data that helps them definitively believe that and understand that. The education piece is critical, and I think it's happening now. I think interventional glaucoma, you go to any major ophthalmic conference, there's a whole lot of talk around interventional glaucoma. By the way, we want to lead the way in creating the interventional dry eye category, right? We're doing a lot of work there, but we're not stopping with glaucoma. I think the more that we can truly make eye care providers believe that earlier intervention is better and I do it on a regular basis, we think that's the best way to get more interventional care to patients. Yeah, we have a lot on dry eye, don't worry. I'm anonymous in that. Q2 was actually pretty strong from a surgical glaucoma standpoint. Ali, do you have a perspective? How durable do you think the drive is behind that all? Yeah, we're really proud of the results that we had in both the first and second quarter. We're competing effectively in a dynamic MIGS environment. We believe that's because OMNI is an important part of the treatment paradigm. It's a comprehensive procedure, addresses all three areas of resistance. When you can only choose one MIGS, it's a natural choice for patients where you want to see high efficacy in the procedure. We're really proud of that. We saw, obviously we knew coming into this year that we would have some headwinds associated with the MIGS restrictions that were put into effect last November. We think that we're executing effectively here. We're continuing to engage with our accounts. We're seeing all-time record in number of ordering accounts, increasing sequential utilization up 12%. Overall, our surgical glaucoma revenue was down mid-single digits, which is substantially better than the 15% headwinds associated with the multiple MIGS restrictions. We're really proud of our second quarter performance. We think our team has done a great job in this environment. It was a great result. I'm going to ask an unfair and unanswerable question, which is a great combo. Why do you think, what is with the MACs and Medicare's constant fiddling with glaucoma as a category? It's not a massive cost line for them compared to others. It seems bizarre. It's not like people are hugely over-earning. I know it's kind of unanswerable. I've always got this question. I don't know how to answer it. Yeah, I mean, it's been tricky over the years, to say the least. Lots of surprises. I think we understand the attention when a category is fast growing. MIGS has been one of the fastest growing segments in ophthalmology for many years. It is, I mean, there's a need, a clinical need for more effective, less invasive treatments. Eye care providers and ophthalmic surgeons have adopted those technologies clearly. It's been an attractive growing market. With that growth comes scrutiny. I think people are trying to figure out, payers, even surgeons are trying to figure out what are the best approaches. For example, with the LCDs and multiple MIGS, you can see surgeons saying, "I'd rather take two minimally invasive approaches that might add up to the efficacy of the invasive approach, but have a much better safety and complication profile." Right? Hence the multiple MIGS. We obviously believe in throwing multiple mechanisms of action. OMNI is indicated to perform two procedures, canaloplasty followed by trabeculotomy. We subscribe to that thesis of doing more minimally invasive procedures can maybe get you close to the efficacy of an invasive procedure. That being said, payers are looking at this maybe and saying, "We see very robust evidence on each of these individual modalities. But where is the evidence on the combinations of these modalities being significantly better than any one?" In the ideal world, you leave it up to the surgeon, right, and their best discretion for what that patient needs, what will help. For example, on the multiple MIGS, I think there is more clinical evidence showing that multiple procedures are superior to one. Obviously, you know, we want to continue generating more and more compelling clinical evidence with OMNI showing that the combination of canaloplasty with trabeculotomy is a leader in efficacy profile. The relentless neediness of payers for clinical evidence is Max Schoenebeer, my three-year-old. Yeah, it's kind of wild. Maybe OMNI Edge, if we could touch on that. For those who are less familiar with it as a platform, a little bit of background, how are you finding the rollout and everything like that, and how much is incremental relative to replacement, so to speak? Yeah, we're excited about OMNI Edge and the adoption to date. Background on it, we've been innovating the OMNI platform. Predicates to OMNI since, you know, 2015 timeframe. OMNI arrived, launched it in 2018. We've obviously been iterating on the OMNI platform and trying to make it better and better, listening to the market, listening to our surgeons. We partner closely with our surgeon customers to take their feedback and try to embed it into the technology and give them something even more either efficacious, safe, or user-friendly. With OMNI Edge, the primary difference is an increase in the volume of viscoelastic delivered. The first procedure I mentioned, canaloplasty, is a catheterization of an obstructed vessel in the eye that's ultimately leading to high pressure. We allow our surgeons to go in and catheterize that vessel and dilate it with a viscosurgical gel. It's kind of like balloon angioplasty for the eye for glaucoma. We've been increasing over time steadily, carefully, because we want to make sure we're preserving the safety profile. You don't want to overshoot too quickly. We've been steadily increasing the volume of gel or dilation that we offer our surgeons. This one is a leap. It's almost a doubling of the dilation effect. So far, surgeon feedback has been great. Surgeons are adopting it very nicely and providing lots of feedback. We expect it to be, you know, our leading product in due course. A lot of it is existing OMNI surgeons. It's a competitive market. We've created a category. Naturally, others will come in and do their best to replicate. We think that we are many years ahead in terms of our technology, and we're not sitting idle. We're continuing to move our technology forward. Edge is one example of that. We have other iterations in development that we are excited to be announcing, you know, over time, but expect a steady stream of OMNI platform innovations and us staying well ahead of the competition and offering surgeons the best interventional glaucoma, you know, canaloplasty and trabeculotomy treatment. It's interesting you bring up competition. It's a funny market because it's kind of a two-horse race. From a MIGS standpoint, when I think about it that way, even some very well-funded competitors with massive reach coming in have been spectacular failures. Why do you think that is? Is it like surgeon loyalty and just familiarity and confidence? Because it's really been you and one other player dominating the space. I think it's many factors. I think surgeon relationships, but many players, I think, do that sufficiently well. Your technology, how do you assess the technology? Some might tend to overly rely on, you know, this product has slightly better efficacy than that product. That's important, but that's one of the considerations when we assess technology and how, when we assess ourselves and how well we're doing in terms of what we're offering to our customers. We obsess over safety, we obsess over efficacy, we obsess over usability. I think for a number of, you know, whether that's in glaucoma and MIGS or in other areas, either in ophthalmology or in medicine, you might ace one of those things, but if you don't ace the others or you don't get at least high marks on the others, despite tremendous efficacy, you might not become a standard as you may have thought based on the efficacy profile. All of those things are critically important. I think we've done very well with OMNI. We think it has a very good safety profile. We think it has a leading efficacy profile in the MIGS category. Usability, do not underestimate the importance of usability. It's like an iPhone, right? People love their smartphones, like love their iPhones, you know, probably mainly because of usability. They love to use it and it's reliable. We try to do that. We try to approach our technology development that way, not just on the glaucoma side, but also with TearCare that also gets very high marks for its usability. I think the combination of those things coupled with commercial excellence and our team's ability to develop very strong relationships with our customers that are long-lasting, technology plus relationships makes for a good competition. Also, phones, I can just scroll through stuff and have that hollow empty feeling inside afterwards. I don't know. We got to hit on dry eye because it's just such an, it's just like, it's a really interesting space in general, still horrifically treated in the sense that it's functionally untreated despite some therapeutics that are obviously in the market at the moment and some OTC solutions. Maybe for those less familiar, give people a little bit of a background around TearCare, how you see it fitting into the paradigm. Yeah, we started the TearCare journey over a decade ago. We saw a need, just like OMNI. I think our approach to product development, or what we believe is optimal product development, are technologies that we can equip our eye care provider customers with that ideally allow them to intervene, not just intervene, but intervene at the root underlying cause of disease. With glaucoma, that's intervening in the conventional outflow pathway, doing so comprehensively. If you look at dry eye, you can look at the disease through that same lens that we looked at the glaucoma category through. We said, what is causing the majority of this disease? What is the underlying problem for the majority of patients? It's actually not tear insufficiency. The average person would believe a condition called dry eye is the result of not producing enough tears. In reality, the majority of patients and the majority of dry eye patients produce plenty of tears. The problem is those tears are evaporating too quickly. You say, why are they evaporating too quickly? You trace that back to the meibomian glands, which are oil-producing glands in your eyelids. We have 20 - 30 of these oil-producing glands in each of, you know, 120 - 150 glands across all four eyelids. When those glands are healthy, they're producing a liquid oil called meibom, got olive oil-like consistency. With disease, with hormones, with screen time, this is becoming a societal problem where you're staring at screens and your oil is not getting expressed from the glands. It's sitting around and it begins to inspissate and harden. It moves from a healthy liquid olive oil-like state. The mild moderate dry eye might be like toothpaste. It turns into like a toothpaste. In advanced dry eye, this oil hardens altogether. Once it's hardened in the advanced state, no oil is being expressed from the glands. There's no oil coating your tears. When they're healthy, this oil layer on your tears keeps the tear around for a sufficiently long period of time. Without that oil, the tears evaporate immediately. We said the world needs a safe, efficacious, and usable interventional technology for the root underlying cause of the majority of dry eye disease, which is meibomian gland disease. Over a decade ago, we set out to develop what has become TearCare. TearCare, I think today, now with two RCTs completed, including a two-year RCT showing superiority to the standard of care and also showing a very significant durability of treatment effect, I think it's now the most clinically proven interventional procedure for dry eye. We needed to generate very significant and robust clinical evidence to truly create this category, which to us means providing patients with reimbursed access to treatments. Today, this category doesn't have reimbursement for interventional procedures. To create a significant new category, you need really compelling clinical evidence. We spoke with payers many years ago around the need for patient access to a treatment like TearCare and what clinical evidence would be necessary to support reimbursement. The protocol that was designed, which we call SAHARA, our SAHARA RCT, was informed by conversations with payers. We wanted to go head-to-head with the standard of care. It's the best thing you can do from a payer perspective. Ideally, beat it. We did at our six-month endpoint, superior on our primary signs endpoint of tear breakup time. Clinically and statistically significant improvements in every sign and every symptom at six months and at 12 months and at 24 months. Now all three phases have been published. We have health economics publications in hand, a budget impact model, a cost utility analysis. We have an updated RVU analysis. All of those deliverables serve as the foundation for very healthy payer conversations. We are right now in the midst of quality payer conversations. We are working to get something, a policy across the finish line. It's impossible to control when. We are doing everything we can from a top-down and a bottoms-up strategic approach. We've said we're aiming for 2025 policy wins. We're in September. Might we get something done this year? We hope. We're still working towards that. We ultimately, you know, can't control the exact timing. Having a better mousetrap is always helpful. Dry eye, it's a funny category because historically on the therapeutic side, there's been almost no cannibalization at all between any of the therapeutics and each other, which I think speaks to how few patients are actually getting any kind of treatment, right? Correct. Correct. I think it's significantly undertreated. I hope that we can change that with reimbursed patient access to treatments, again, that treat the underlying cause of disease. Our existing TearCare customers have so much conviction in the technology and the clinical outcomes. Their patients get immediate, significant effects, and those effects last. We have proven that through the SAHARA three-stage RCT to further drive that conviction. To create reimbursement in a category that lacks it, you need a lot of clinical evidence. You also need a lot of conviction from influential eye care providers. Thankfully, we have that conviction, and our customers that we enjoy very strong relationships with are helping us with those payer engagements. Maybe it might be worth for people just to make sure we don't skip any steps explaining how TearCare works. It's a little different from taking drops and something like that. For what it's worth, from the feedback we got, I still, I apologize, I still actually haven't had a treatment done yet. We had heard. We need to change that. We heard it's really creepy. Yeah, we genuinely got the feedback. It's like procedurally extremely pleasant, as creepy as that sounds. Yeah, maybe just delineate for people what the actual treatment is. Yep. It's an in-office treatment. The first stage of the treatment, first you discuss the treatment with your eye care provider. Assuming you want to proceed, the eye care provider will affix four therapeutic, adhesively applied, eyelid-worn devices to each of your four eyelids, software sensor controlled. We need to elevate the temperature to the maximum FDA allowable temperature and hold it there. We're trying to thread a needle on a single degree. Get the temperature on the tarsal plate of the eyelid up to 45 degrees Celsius, 113 degrees Fahrenheit. You can't overshoot because then you're going to have skin safety issues. You can't undershoot because then you're going to have efficacy issues. It needs to be a very smart system that's talking to the controller many, many times a second to get to that, to thread that needle on that single degree. Get it up to 45. Fifteen minutes of pushing this max temp into the glands, melting all of those obstructions, again, through conformable, wearable, flexible, thin, sub-millimeter thin, but very smart devices that can melt all of the oil obstructions in each of the 20 - 30 glands in each of your eyelids. That's 15 minutes of thorough melting within the eyelid. After the melting, the eye care provider at the slit lamp will work with the patient. We have a single-use clearance assistant that allows the eye care provider to go zone by zone on each eyelid to maximally express and clear this diseased oil that's now in its melted phase. Clear all of it. That's the aha moment for doctors, by the way, when they see the significant evacuation of what was once hardened diseased meibom that's now been melted and is getting expressed. It's got a different color than it should. In fact, we give treatments at conferences. We can do one for you in public. Our team insisted I do one at the last conference. That was quite the experience. You had one also, right? That's the aha moment when they see the volume of diseased meibom with just a little bit of pressure because we've melted it so well. When it's being evacuated from the gland, they know that the patient's going to have immediate symptoms and signs improvements, and the data says that they will be durable. It's also satisfying. Yeah, in that way. It's melt everything in all four eyelids at once. You have a 15-minute session with all four devices affixed to the eyelids, and then lid by lid, zone by zone, five to ten minutes, clearance of each eyelid. How are you thinking about, because we'll get back to the payers and coverage and that side in a sec, but assuming that all goes, how are you thinking about sort of patient activation? You kind of, there's a word of mouth component, there's maybe an awareness, like whether it's advertising or like, how are you thinking about getting that awareness out there? Yeah, so first of all, I think it's important to understand that this is the number one reason people go to their eye care provider is because of dry eye symptoms. This is a large patient population. There are over 19 million diagnosed with dry eye disease in the United States, and there's another 19 million undiagnosed patients. This is a huge problem. People have experienced pain and discomfort and go seek treatment from their eye care provider, and that's very common. Having that eye care provider first and foremost identify that they have dry eye disease and then identify that they have gland blockages that would benefit from a TearCare procedure, identifying the root cause of what's causing their dry eye disease and then with reimbursement, being able to provide them a treatment pathway. Right now, their options are to prescribe drops. That's, you know, first of all, there's compliance adherence issues with patients doing drops two times a day, four times a day, depending on the drop. It is significant, but patients are doing it because they are seeking an option that will help with the issues that they're experiencing and the symptoms. Providing the ECP with another option, I think anybody when thinking about the options of, okay, a doctor tells you you can do a drop two or four times a day, or you can do a procedure right now, it'll take about an hour in the office. You do that once a year or maybe twice a year, depending on severity. Most patients are going to pick the procedural intervention, particularly because it is, you know, a pleasant experience. As you said, it's not something that is a surgical procedure. It's a quick intervention in the office with this process. That's really compelling for patients. It's also very compelling for eye care providers. You think about it, this is the number one reason people come into their office, and most of the time they write a prescription associated with that. They aren't participating in the economics of that treatment approach. With the procedural intervention where they actually have to do work, they actually can participate in the economics as well. As we proved in our budget impact analysis and cost utility analysis, this saves the payer money too. It's really an incentive for patients, it's an incentive for providers and payers, and that's fantastic. That's what happens when you have something that really has high adoption, when you can be a win for all of the players that are impacted by this. That's what we're hoping to achieve with TearCare with the appropriate reimbursed access to the technology. From our perspective, it really comes from the patient going into the office seeking care and the ECP prescribing the appropriate treatment for that patient. Over time, you see with a lot of dry eye drops, MIEBO has done a ton of consumer advertising. We love that in the sense that it's driving awareness of MGD. That is something that is not well understood by the community and patients. That awareness, I think, will help when people are then understanding they have MGD and then what are the treatment solutions there. There could potentially be a direct-to-consumer play at some point. It's certainly possible. We need coverage density before we would consider those types of investments. In the meantime, let's not forget, once we secure reimbursement, we have spent years in the market, not necessarily driving revenue, but training dry eye specialists across the country on the procedure. We have over 1,500 SmartHubs out there that have been sold. These are from eye care providers that have already demonstrated a desire to begin treating MGD as a treatment modality for their dry eye patients. Those 1,500 installed hubs already have access to plenty of patients. We need to turn them back on with coverage policies. Yeah. It's actually, to your point, like that was sort of why I was hinting at the lack of cannibalization is actually because of that co-effects of MIEBO was one of the things that I get a lot of feedback that I'm terrible at my job, but one of the ways that I know I'm bad is actually just hearing you reference it. It reminds me of another company that added $4 billion of market cap for a surgical procedure that reduces the number of drops that you have to take. I mean, I never made that analogy between the two in my head, but it's kind of interesting thinking about it that way. On the discussion with the payers, you know, SAHARA, that helps a lot. What's the feedback been? Like, how are they thinking about coverage? Is it harder because it just looks a bit different? What are the conversations? I'd say the feedback on the SAHARA RCT has been very positive. Not surprising, again, because we didn't conduct the study or design the protocol blind. We talked to payers and a variety of medical directors, some ophthalmologists, some not ophthalmologists, to make sure we understood what they would need to see to support coverage. The feedback to SAHARA stage one, stage two, and now stage three, the 24 months, has only recently been published. That is also very compelling and being very well received. We also have the economics piece, which, you know, obviously payers don't announce that that matters a lot, but I mean, the economics matters to everybody. We have the budget impact model, which is compelling, and also the cost utility analysis, which tells a very clear story to payers that not only is this more clinically effective, but it also is more economically appealing. The feedback has been positive. In terms of timing, we would have loved to have had a policy win by now. Why have we not? Look, we're trying to do something new in a big new category. There's a reason why we had to run and wanted to run such an aggressive, rigorous RCT. You cover dry eye. You've seen the RCTs. They're usually one month or three months. They're pretty terrible. In feedback. The control arm isn't the gold standard therapeutic. It's usually against, and I'm not criticizing the other RCTs. I'm trying to shine a spotlight on how rigorous the SAHARA RCT is because it needs to be. Most of the other comparator arms in RCTs are against vehicle or saline. We randomized against the therapeutic gold standard, and we didn't give Restasis one week to work or a month to work. We had to ensure compliance. We randomized against twice daily Restasis compliant for six months straight. Rigorous RCT, but we knew we needed to bring to payers to create reimbursement in a category that affects a lot of patients, this level of rigor. Ideally show superiority. We've done that on our primary science endpoint. We've shown clinical and statistical significance on all signs and all symptoms, and we've shown durability of treatment effect. This is exactly the kind of clinical information payers need to see. Why don't they have a policy immediately? Creating a new category, the timing, these things take time. We feel good. We're making progress. When will we get that first win? Again, we're working on a 2025 win. We've had quality conversation. The data has been very well received. How do we get it across the finish line? That's what we're working on. There are people with jobs and time, you know what I mean, a lot going on. It takes time. I mean, that doesn't help either. From a Medicare perspective, there's a lot going on with Medicare and the MACs, and they're generally behind also. That has also been, you know, one factor. It's a great place to finish. Ali, thank you so much for doing this. Yeah, thank you. Great discussion. Thank you. I appreciate it. Thanks. All right.