STAAR Surgical Company

Welcome to the Star Surgical first quarter 2024 earnings call and webcast. During today's presentation, all parties will be in a listen-only mode. Following the presentation, the call will be open for questions. If you have a question, please press the star key followed by one on your phone. Please note this call is being recorded today, Tuesday, May 7th, 2024. I would now like to turn the call over to Brian Moore, Vice President of Investor Relations of Star Surgical. Please go ahead.

Thank you, Operator. Good afternoon, everyone, and thank you for joining us to discuss the company's financial results for the first quarter end at March 29, 2024. On the call today are Tom Frenzy, President and Chief Executive Officer, and Patrick Williams, Chief Financial Officer. The press release of our first quarter results was issued just after 4 p.m. Eastern time. We have posted the earnings release and our earnings presentation supplement to the investor relations section of STAR's website at www.star.com. Before we begin, let me quickly remind you that the company comments during this call will include forward-looking statements. We caution you that any statement that is not a statement of historical fact is a forward-looking statement. This includes remarks about the company's projections, expectations, plans, beliefs, and prospects. These statements are based on judgment and analysis as of the date of this conference call and are subject to numerous important risks and uncertainties that could cause actual results to differ materially from those expressed or implied by such forward-looking statements. The risk and uncertainties associated with these forward-looking statements are described in the Safe Harbor Statement in today's press release. as well as STARS public periodic filings with the SEC. Except as required by law, STARS seems no obligation to update these forward-looking statements to reflect future events or actual outcomes and does not intend to do so. In addition, on this call and in the press release, we discussed certain non-GAAP financial measures, including adjusted EBITDA and adjusted EBITDA per share. We also provide sales data in constant currency, Definitions and reconciliations to GAAP are included in today's press release. For brevity, unless otherwise specified, all comparisons on today's call will be on a year-over-year basis versus the relevant period. Following our prepared remarks, we will open the call to questions from publishing analysts. We ask analysts limit themselves to two questions, then re-queue with any follow-ups. Finally, we intend to use our website as a means of disclosing material non-public information and for complying with our disclosure obligations under Regulation FD. Such disclosures will be included on our website in the Investor Relations section. Accordingly, investors should monitor our investor website in addition to following our press releases, SEC filings, and public conference calls and webcasts. And with that, I would now like to turn the call over to Tom Frenzy. Tom?

Thank you, Brian, and good afternoon, everyone. I'm pleased to report STAR generated net sales of 77.4 million for the first quarter of 2024, which exceeded our outlook. Our enhanced commercial focus is yielding positive results, and our proprietary EVO-ICL lens-based technology again delivered above market rates of growth across all key geographies. We exceeded our original expectations for the quarter even in a down market for the predominant procedure in our industry, laser vision correction. Evo is taking market share, building the channel for refractive vision correction, and our momentum is growing. We are proud to report multiple business and execution milestones in the first few months of 2024, including today's announcement of the largest commitment ever to Evo ICL in the US, a strategic agreement with Dr. Robert Lin and IQ Laser Vision as part of our US Highway 93 go-to-market program. Thus far in 2024, we generated 21% sequential sales growth in the US, achieving record quarterly US ICL sales of 5 million. We believe this represents a new base level of quarterly sales in the United States. Our agreement with Dr. Lin is the largest ever commitment to EvoICL in the US to date and follows on the agreement we announced with Sharp Vision also in the first quarter. We have qualified a dozen US Highway 93 Evo ready customers to move into the fast lane, if you will, and signed agreements with HAF since the program launched in the fourth quarter of 2023. These fast lane customers believe in the merits of EvoICL and are increasingly recommending the EVO procedure to their patients. They are committed to growing EVO as a percentage of the refractive procedure mix, initially targeting 15 to 30%. Dr. Lin has implanted over 1,000 ICLs in the prior 12 months, and his initial target under our new strategic agreement is 1,500 ICLs, representing significant growth over the prior year period. Last month, we engaged hundreds of surgeons at the ASCRS, the American Society of Cataract and Refractive Surgery's annual meeting in Boston, where ICL was featured in 44 poster and paper presentations during scientific sessions at the meeting. At least two papers were presented that we believe will meaningfully increase surgeon confidence in the measurement of the eye and ICL lens size selection. We also launched STAR Universities, our medical science website at ASCRS for surgeons and other healthcare professionals. STAR University will feature clinical data and research, including the papers I just discussed. And work is underway to further expand STAR University's features, including videos and a surgeon training portal. We also introduced our Stella ordering and planning system at ASCRS. Stella will enhance surgeon efficiency and practice flow and is the initial step towards a comprehensive EVO-ICL ecosystem. We have drawn a line in the sand to be the choice for minus six and above as our next step in moving down the diopter curve, which represents a significant growth opportunity. When we surveyed surgeons with our clinical data at both ASCRS and our recent Asia Pacific Expert Summit, 93% of those surveyed agreed or strongly agreed that based on the data presented, They were more comfortable recommending Evo ICL for patients minus six and above. And finally, in the first quarter, we reached and celebrated 3 million total implantable columnar lenses sold. Half of those ICLs were sold in just the last three years. Turning my attention now to our regional results for the first quarter of 2024, we generated ICL sales growth of 9% in the Asia Pacific region, including 10% growth in China. In the first quarter of 2024, the APAC region outperformed our full year of fiscal 2024 outlook of 7%. And China growth in the first quarter was ahead of our expectations, despite a tough comp in the year-ago quarter, which reflected pent-up demand following the removal of COVID-19 restrictions in the fourth quarter of 2023. We generated 11% sales growth in the EMEA region, which exceeded our outlook for flat sales growth for the full year fiscal 2024. Growth was driven by the Middle East and our European distributor markets, which includes newer hybrid markets such as Belgium and the Netherlands, where we began investing just a few years ago and now have reached approximately 20% share in each market. In our Americas region, we generated sales growth of 12%, including 15% sales growth in the U.S., which also grew 21% sequentially. Our results in the U.S. outperformed our outlook for flat growth in the first half, and once again, we believe we have achieved a new base level of U.S. quarterly sales. We saw returns on our strategic investments in 2023 during the first quarter of 2024. As many of you may recall, It was just about a year ago when we began making critical investments to drive our business forward. In April 2023, we made an investment in people, adding a chief operating officer and a chief clinical regulatory medical affairs officer to our leadership team. In the third and fourth quarter, we added three new customer facing vice presidents. And last week, we announced our new general counsel and chief marketing officer. These individuals are already having a positive impact on our business and will further accelerate EVO-ICL uptake, our market share capture, and innovation. We have invested in our field organizations globally with new hires in both large and emerging markets, including China, the US, India, and Brazil. In China, for example, we expect to end the year with more than 100 star employees as we lean into the growth opportunity in the largest market for refractive vision correction. We aim to continue the strong business momentum we have achieved against the headwind of lower consumer discretionary spending. We have been disciplined in our investments and as a result have built a record level of cash on our balance sheet. We are confident that our business model is structured to continue to generate and build cash based on current trends, we are reiterating our fiscal 2024 net sales outlook range of $335 million to $340 million. We acknowledge the challenging and dynamic macroeconomic and geopolitical environment, but based on our stronger than expected first quarter results, we expect to be at the higher end of the range. Patrick?

Thank you, Tom, and good afternoon, everyone. Our Q1 2024 results were slightly better than what we reported in our April preliminary announcement in the key areas of net sales, profitability, and cash. Total net sales for Q1 2024 were $77.4 million as compared to net sales of $73.5 million in the prior year quarter. As a reminder, Q1 and Q4 have historically represented our seasonally lowest quarters. The $3.8 million increase in Q1 2024 net sales is attributable to a 9% or $6.5 million increase in ICL sales, partially offset by a decrease in Cataract IOL, which the company wholly exited in fiscal 2023. Changes in constant currency negatively impacted total net sales by approximately $1 million or approximately 130 basis points in the first quarter of 2024. During the quarter, we successfully added a second distributor for our China operations. We are very pleased with how smoothly this has gone, and the new agreements in place have resulted in higher net ASP realized across our total business in China. For Q1 2024, gross profit was $61 million, or 78.9% of net sales, as compared to gross profit at $57.6 million, or 78.3% of net sales for the prior year quarter. and $60.7 million, or 79.6% of net sales for Q4 2023. The year-over-year increase in gross margins is primarily due to country and product mix. The sequential decline in gross margin is primarily due to inventory adjustments. For 2024, we continue to expect gross margin will be approximately 80% of net sales for each quarter and the full year. Moving down the income statement, total operating expenses for Q1 2024 were $63.3 million as compared to $54.8 million in the prior year quarter and $50.3 million in Q4 2023. The increase in operating expenses reflects our decision to lean into investments to build the market for Evo ICL as we build a foundation for future growth and margin expansion in the later years of our strategic plans. Taking a closer look at the components of operating expenses, G&A expense for Q1 2024 was $23.2 million compared to $18.1 million in the prior year quarter and $16.9 million in Q4 2023. The year-over-year increase in G&A is primarily due to increased outside services and facilities costs. The sequential increase in G&A is due to compensation-related expenses and outside services. For 2024, we continue to expect G&A expense to be approximately $24 million per quarter. Selling and marketing expense was $26.7 million for Q1 2024 compared to $26.4 million in the prior year quarter and $22.6 million in Q4 2023. The increase in selling and marketing expenses from the prior year was due to increased compensation-related expenses, trade shows, and meeting expenses offset by decreased advertising and promotional activities. For 2024, we continue to expect selling and marketing expense will be approximately $30 million per quarter, which is consistent with prior periods as a percent of net sales. Research and development expense was $13.4 million for Q1 2024, compared to $10.3 million in the prior year quarter and $10.9 million for Q4 2023. The year-over-year increase in R&D is due to compensation-related expenses. For 2024, we now expect R&D expense will be slightly higher at approximately $14 million per quarter as we increase investments in our Department of Global Professional Education and Training, as well as STAR University. For Q1 2024, net loss was $3.3 million or $0.07 loss per share compared to net income of $2.7 million or $0.05 income per share in the prior year quarter. During the quarter, we had a $2.3 million loss related to foreign currency exchange, which drove the majority of our net loss in the quarter. This is related to cash generated from our Japan business, which requires us to mark all cash investments back to U.S. dollar from yen. which has been weak at record levels versus the U.S. dollar. Consistent with our previously communicated profitability expectations for the first quarter, we did have a gap loss in the quarter, but significantly outperform on adjusted EBITDA, coming in at $5.3 million, or 11 cents per share, compared to adjusted EBITDA of $10 million, or 20 cents per share in the prior year quarter. As a reminder, we introduced adjusted EBITDA as a profitability metric that we believe more accurately represents the underlining performance of our business model on an absolute basis and relative to our peers. We believe that an adjusted EBITDA financial metric or adjusted earnings before interest, taxes, depreciation, amortization, and stock-based compensation provides investors with an additional tool for evaluating the company's core operating performance and a proxy for cash generation. We use this non-GAAP financial measure in our own evaluation of operating performance and believe it is a more useful reflection of our progress. A table reconciling net income to adjusted EBITDA for prior periods is included in today's financial release. In order to reconcile adjusted EBITDA from net income for our fiscal 2024 profitability outlook, we are providing the following line item details. Revision for income tax unchanged to be calculated using an effective tax rate of approximately 35% per quarter, subject to no significant change in our valuation allowance. We now expect other income expense to be slightly better at approximately $0 per quarter. Depreciation unchanged at approximately $1 million per quarter. Amortization unchanged at $0 per quarter. And we now expect stock-based compensation to be slightly higher at approximately $8 million per quarter. As Tom said, we are reiterating our fiscal 2024 sales outlook range of $335 million to $340 million. Though based on current trends, we do expect to be at the higher end of this range. For the second quarter of 2024, we anticipate net sales of approximately $95 million, which continues to contemplate above market rates of growth globally in all key markets. Based on our Q1 profitability performance and after mentioned changes to our income statement line items, we now expect our full year adjusted EBITDA will be approximately $3 million higher or $39 million. and using approximately 52 million shares outstanding results in an adjusted EBITDA per share of approximately 75 cents up from 70 cents. Turning now to our balance sheet, our cash, cash equivalents and investments available for sale reached a record $252.1 million at the end of the first quarter 2024, as compared to $232.4 million for the fiscal year end 2023. This was better than anticipated in our preliminary announcement, as was our progress on reducing accounts receivable to $64.6 million. Notably, this reduction in accounts receivable was related to our China business, and we are back to historical levels as a percent of sales across all customers globally. We look forward to meeting with many of you in the days and weeks ahead. We will participate in the Morgan Stanley Virtual Asian Conference next week and the Goldman Sachs Healthcare Conference in June. We will also participate in in-person investor meetings in Hong Kong, Shanghai, New York, and Southern California. We expect to report our second quarter results in early August. This concludes our prepared remarks. Operator, we are now ready to take questions.

Thank you. We will now begin the question and answer session. To ask a question, you may press star then one on your telephone keypad. To remove your question, please press star then two. Today's first question comes from Margaret Coxner with William Blair. Please go ahead.

Hey, good afternoon, guys. Thanks for taking the questions. The first question for me is really around the U.S. I mean, you guys had a great quarter, you know, really nice feat to your expectations, our expectations, you know, great sequential growth. I think you were expecting 10% for the full year. It sounds like you're still expecting that. So... the issue is if I keep the U.S. flat at $5 million and a quarter for the rest of the year, it gets you above that range. So I guess, you know, what's implied for the cadence for the U.S. throughout the remainder of the year? Do you still expect that $2 million step-up that you used to talk about in the second half or not? And any kind of details kind of on these new Highway 93 partners like Sharp Vision and now IQ Vision metrics since those folks had entered the programs?

Yeah, hi, Margaret. Thanks for the question. And, you know, look at where, as we said in the pre-announcement, we reiterated here today, we were very pleased with the U.S. results coming out of Q1, certainly ahead of what we certainly signaled as we started 2024. And I think, you know, when you build a new category of lens-based refractive surgery, it takes time. and the investments we made and the strategies we put in place during the course of 2023 are beginning to bear fruit, resulting in agreements we signed with people like Shark Vision and IQ Laser. And I think, look, one quarter does not make a year. We're trying to be prudent. I think we're confident that we've established a new baseline of business, as we mentioned here, at around $5 million per quarter. Do I think we have upside opportunity in the back half of this year as we signaled originally? I do, but we're trying to just be cautiously optimistic, you know, given some of the macroeconomic headwinds that are out in the marketplace. So I think Q2, we'll see how that plays out. But clearly with laser vision correction being down at 19% in Q1 and EVO being up 15% year over year, I think speaks volumes to the market is beginning to really embrace and engage lens-based refractive surgery.

Okay. Yeah, that's helpful. So we'll hopefully look for some metrics maybe around the highway and IDQ partners as we go on throughout the year, it sounds like. And you had referenced macro a little bit in that answer. Tom, so, you know, can you give us any update or flavor as to what you're anticipating, if there's any change at all within guidance on the macro environment, stable, improving, getting worse, especially as we think about markets like China? It's great to hear ASPs are increasing, Tom, but maybe you can chew us up a little bit on how you guys are thinking about that going into Q2 and the rest of the year. Thank you.

Yeah, you know, obviously none of us are economists, and, you know, we read, as I've mentioned previously, the same headlines we all see in the papers, and I think in particular in China, it's continuing to be a choppy economic environment. We saw a nice growth in January and February. We saw a little bit of a slowdown in March in China in particular. We saw it continue into early April, but the back half of April and one week or so into May, we're encouraged by some uptick in the China market. And again, we thought the market would be relatively flat. We're pleased that we came in with 10% growth. We signaled early in the year that we thought the back half of the year in China, we would see some nice uptick there and we continue to believe that. So again, we're trying to be prudent. We're trying to be cautiously optimistic. Our China business is in good shape as many of our other markets are as well, because we saw growth in Q1 across all of our major geographies.

Great. Appreciate it, guys.

Thank you. And our next question today comes from Tom Steffen with Stifel. Please go ahead.

Great. Hey, guys. Thanks for the questions. Maybe I'll start with the U.S. In one queue again, you know, nice to see the early momentum. I guess qualitatively, Tom, can you elaborate a bit on sort of what you believe specifically is going well as you continue to refine your U.S. EVO strategy? Are there any noticeable areas of improvement you're finding of late, whether that's in your execution, maybe with doctors or with patients?

Yeah, I think, Tom, first of all, thanks for the question. I think it is across the board. You know, as I said, we concentrated on surge in confidence around measurement and lens size selection. And the papers that we published in the first quarter, I think, gave people added support and data and confidence that, you know, you could perform this procedure safe and effective. I also think in the U.S., look at whether you want to call it fear of missing out or herd mentality. As we're building momentum, as we're signing new agreements, in addition to the two we have mentioned, you know, we signed four additional agreements since the end of 2023 that are just demonstrating that lens-based refractive surgery in the face of declining laser vision correction is becoming more and more meaningful in the practices. So, yes, our execution is better. We're surrounding the customer in a more effective way. We have new tools to bring to bear at the practice level. And all of that is giving us real confidence that we're beginning to crack that code, if you will. And I think it's been reflected in our numbers.

That's great color. Thanks, Tom. And then my follow-up question is just on guidance. You beat 1Q by, I think, over $5 million. but for now only have raised by basically $2 to $3 million. I know there's conservatism and you want to be prudent, but can you talk about key reasons why maybe you didn't flush through all or at least more of the 1Q upside, just as we kind of look ahead at the rest of 24? And then, Patrick, a quick follow-up for you. Any additional color on cadence of revenue for the rest of the year? Sorry if I missed that. Thanks for the questions.

Sure. I think in terms of the first part of your question, you know, I think it is just prudent. You know, let's see how Q2 comes in. And I think, you know, we'll react accordingly. Q4 was a strong quarter for us in 23. Q1 following up. And I think let's see how Q2 comes in. And then as we either pre-announce or talk in August, at our next earnings call, stay tuned.

Yeah, and we had said approximately $95 million for Q2 based on our current trends that we're seeing out there.

Thank you. And our next question today comes from Patrick Wood at Morgan Stanley. Please go ahead.

Amazing. Thank you so much for taking the questions. I'll keep it to two. I guess... Given the progress we're seeing in the U.S., and I know it's early days in the turnaround, but big picture, longer term, can you think of any structural reason that the U.S. couldn't get to the high teens to low 20s, you know, ICR penetration rates that we see in quite a lot of EMEA?

Yeah, look, Patrick, I think it's a fair question, but, you know, whether it's 10%, 15%, 20%, 30%, I think we just have to keep our head down keep doing the things we're doing that we know are moving the needle, increasing surgeon confidence, providing the kind of clinical and marketing support. As we said, we thought it was appropriate to kind of adjust our spend away, if you will, from brand awareness to more downstream marketing and really surrounding the customer clinically and commercially. And we've been doing that. We'll continue to do that. And I think as we execute, as we did in Q1, I think the numbers will bear out what it's going to bear out, but we remain confident that lens-based refractive surgery is becoming more meaningful in each of the practices that are embracing Evo.

Totally get that. And then, you know, I guess it's not up for you guys in a way to sort of speculate to some degree, but, you know, Why do you think the refractive market in the U.S. is so weak at the moment? Is that a read on the consumer? We get mixed signals there. I appreciate you're taking a lot of share out of that slowly, but why do you think the market overall is having a difficult time?

Yeah, I think historically in vision correction, there's been a fear factor and there's been a cost factor. With the choppiness in the economy, I think people are playing it a little closer to the vest in terms of discretionary spending. But, again, we're encouraged because in the face of that reality, we're continuing to outpace the market. So clearly we're overcoming the fear factor, and people are seeing value in what Evo is delivering in terms of post-operative outcomes. So it gives us certainly confidence that we'll continue to outpace the market.

Thank you. And our next question today comes from Young Lee with Jefferies. Please go ahead.

All right. Thanks so much for taking our questions. Maybe starting with the U.S., it seems like the 1QB was fairly broad-based. I wanted to hear a little bit about how Highway 93 accounts performed versus non-Highway 93 accounts. And maybe thoughts on, you know, you guys adding more practices into Highway 93 or maybe training or retraining some practices in 24 and 25.

You know, again, thanks, John. I've said on several occasions, I didn't think we needed to go wider. We just needed to go deeper. Look, we're never going to walk away from the demand that's out there. We're continuing to take on. new customers, but our uber focus on the Highway 93 initiative is bearing fruit, so we're continuing to focus on those practices that are set up for success, whether that's a setting of care, whether that's a committed surgeon and staff, whether it's clinical coordinators that are really confident in speaking to the benefits of our EVO technology, et cetera, et cetera. I think right now we feel very confident that there's probably a 10% to 20% base of those 93 accounts that are really embracing the technology. Again, this idea of herd mentality, fear of missing out, as they continue to be on the podium. A great example, ASCRS in Boston, we went from a year ago 20 or 25 presentations to 40 to 45 presentations. So, you know, we're part of the flow of commerce now. And that, you know, gives us added confidence of where this technology is going to go in the U.S.

I think directionally, you know, we're not going to do specifics, but we did see the Highway 93 perform better on a year-over-year basis than what we'll call the other 400 accounts. But I think that speaks volumes to what Tom said a couple times now, which is the benefits of that. But not only the U.S., but as we move forward and the rollout of Star University, the increased focus on surge in confidence, you're going to hear us talk a lot more about that as we move throughout this year, not just for the U.S., but how we're going to roll that out across the globe because it's imperative that we continue to move down the dioptric curve and really begin owning minus six and above.

All right, great. That's very helpful. I guess to follow up on China, You know, for the results in the first quarter, it seems like, you know, you started the quarter pretty strong. Maybe towards the end, there was a little bit of pressure. Heard the $95 million guidance for the second quarter. Seems like there's some conservatism built in it starting off the year. But wanted to hear a little bit more about the China performance intra-quarter, especially towards the end of first quarter. And, you know, any early comments on the second quarter so far as you entered the toughest comp of the year?

Yeah, Young, as I previously mentioned, I think, you know, we saw a good, strong January, February, a little softer in March that continued through the first part of April. But the back half of April and early in May were encouraged by what we're seeing.

Yeah, I think overall, you mentioned the 95 million that we just talked about for this year in Q2. I think we need to remember this time last year, it was a tough call. The first half of last year was very strong. APAC, China specifically, was very strong. As we came out of the COVID restrictions, going into Q2 especially, a lot of enthusiasm was out there. And then we, of course, saw the procedures just weren't as robust. So, you know, I think, you know, we feel good about the $95 million. Our goal this entire year is to put numbers out there that we feel good about, that we feel confident about. We obviously overperformed in Q1, and we'll see what happens in the next 90 days as we report Q2. But wanted to make sure that people do remember a little bit of history, and we are coming up a pretty hard cop related to Q2.

Thank you. And our next question comes from John Young at Canaccord. Please go ahead.

Hi, Tom and Patrick. Thanks for taking my question, and congrats on the quarter. I also kind of want to circle back to China here, too, if we can. I know you guys traveled there recently, or at least talked about Q4 call. So I would love to get your perspective of what you saw on the ground there that's supporting the growth outlook that you're talking about today, and specifically any updates on either the local growth lens competition that may be coming the second half of this year or any impact from DPP that we should be thinking about? Thank you.

Yeah, no problem, John. Thanks for the question. I was there in, I think it was February or March of this year, on the back end of our expert user meeting that was in Japan. And again, I continue to be impressed every time, and I've spent three trips there in the last 15 months, that restaurants are crowded, malls are crowded, people are out, you know, spending money. And again, in our largest account in that region, they had a very good Q1 year over year. And again, as Patrick said, that's, again, it's a pretty strong comp. So I continue to feel good every time I'm there in terms of the consumer reaction, clinics are busy, et cetera, et cetera. So my confidence remains high. You know, China is a big part of our revenue today. It will continue to be a big part of our revenue, and we continue to invest appropriately. We hope to probably exit this year going from about 80 employees on the ground to over 100, again, demonstrating our commitment to that market and that market's commitment back to us.

Yeah, maybe to add, you know, part of it is adding the second distributor that we talked about in our prepared comments, but trying to become, you know, more efficient, being able to deliver products more timely, especially in those Tier 3 and Tier 4 cities, and that was a big reason why we did bring on the second distributor, which had a much larger infrastructure within China. So, you know, that perhaps gives us an opportunity to get some more people out there.

Great. And then just to circle back, have you guys seen any updates on the local competition from the acrylic-based ones or are thinking about any VBP impact? Thanks.

Yeah, no, I think what we continue to hear that, you know, they could come to the market sometime in the second half of this year or early into next year. But, again, as we have said in the past, John, and you've heard it from us a couple of times, I think competition is a good thing that they're coming. It validates the market opportunity. All boats rise, if you will. But, again, a couple things about that product in particular. It's an acrylic material. That material has certainly come to the market in the past and not been successful. It will only be spherical and not toric, and about 50% of our revenue comes from the toric side. So we think that's going to hamper that rollout. But we're certainly cognizant of, respectful of competition coming. But I think we have strategies in place and a strong team on the ground to be able to continue our momentum, even in the face of competition coming.

Thank you. And our next question today comes from Anthony Patron in Mizzouville Group. Please go ahead.

Thanks for taking the question. I hope everyone's doing well. I'll have one on China and one on the U.S. On China, Tom, curious just your thoughts more on the stimulus program announced in March. And we have a couple of companies focused in China and different areas of med tech. And, you know, there is a thought that in the second half we can see some momentum from stimulus specifically. So any thoughts on how stimulus plays out for ICL in China into the second half? And then I'll have one quick follow-up on U.S.

Sure. Yeah, Anthony, obviously customers seem encouraged by the stimulus. As we signaled, we thought originally we would see a relatively flat first half of the year in China with growth in the second half. We've obviously seen the growth in Q1. So I think stimulus is being well-received, and our customers have certainly signaled to us that, the second half of the year, they should feel the impact of it.

That's helpful. And a quick follow-up on U.S. At the ASCRS meeting, it had some studies on just vault measurements and how that plays out in the surgeon training, but also just implementation real world. So just wondering your latest thoughts on vault measurements in the U.S., You know, what is the timing for potentially seeing a software program that can streamline that process? And do you still, you know, view that as a barrier here in the U.S. adoption curve? Thanks again.

Well, I think as those papers indicate, you know, we had three actually come out while we were in Boston. One in particular dealt with the difference between all the various biometers that are out in the marketplace and in a sense created a surge in the fudge factor that certainly could help surgeons as they make those measurement and lens size selections. We do believe that's part and parcel of the confidence factor that's out there. We are working with several independent investigator trials around whether it has to do with AI learning, whether that's whether it's using UVM or intersegment OCT. And I think certainly in the second half of this year, we'll continue to have more clarity around how that gets to the marketplace, but already doctors are implementing some of the available tools that are available, not necessarily through STAR, but physician to physician. And I think that is playing a role in doctors' confidence growing and their embracing of not only lens-based refractive surgery, but EVO-ICL in particular.

Thank you. And our next question today comes from George Sellers at Stevens, Inc. Please go ahead.

Hey, good afternoon, and thanks for taking the question. Maybe to switch gears back to China, I'm just curious, within your 10% growth expectation, could you just give us some additional detail on what that assumes from the market, from the higher net ASP, Patrick, that you mentioned, and then also in the context of your new distributor, what's the expectation for growth and contribution from Tier 3 and Tier 4 cities versus Tier 1 and 2 cities?

Yeah, we haven't broken out that detail yet, and I think the way to think about the 10% is really focusing still on the Tier 1 and Tier 2. The opportunity is not just this year's Beyond, it's more those Tier 3 and Tier 4s. In terms of the 10%, look, you know, the market was in Q1 probably in China flat to even down. You know, we don't have exact science on this, but depending on who you poll, we even heard numbers in the refracting market that might have been down minus 5, minus 10%. So we clearly continue to take market share. We did see that Ayer reported as a public company. They definitely saw some growth on the top line, but they saw tremendous growth on the bottom line. One could potentially say that there's a bit of a switch out where Refractive is getting moved over to Evo because it is highly profitable for them specifically and for other customers in China. But I think overall our 10%, look, we're obviously holding the line. Most of that is unit growth on a year-over-year basis. We did get some good economics out of the two distributors as part of the agreement that I mentioned. Maybe a couple hundred basis points of that 10% is related to that. We're cautiously optimistic as we enter a Q2, which is the beginning of the high season, and, of course, the costs become a lot easier in the second half of the year.

And, George, I would just add that our decision to add a second distributor was that one plus one is going to equal a hell of a lot more than two, but it's a long-term play, and we're very pleased with how the second distributor has come up to speed and how both are working together and collaboratively complementing one another. So we feel we're very well positioned in that marketplace today and tomorrow.

Okay, that's really helpful. And then maybe on... Europe and more broadly, EMEA. I think you mentioned an opportunity to potentially take some of the commercial initiatives and best practices that you've started to develop here in the U.S. and expand those more internationally. I'm just curious how you think about that opportunity. What kind of a difference, what some of those particular best practices that you've developed are in the U.S. with getting doctors more comfortable with the procedure and

um the the impact that could potentially have on some of your european market growth yeah again we're very pleased with what's going on in iman you know again a relatively flat market and we saw a nice double digit growth there uh and and we do have a similar program uh called the autobahn 50 if you will and and we're seeing really nice growth um in that select group of accounts quarter over quarter and year over year. So the Highway 93 in the U.S. obviously was very U.S. specific, but we knew it would have tentacles that could be globally applied, and we're seeing that bear some fruit in Europe as we speak.

Yeah, I think from a global standpoint, coming back to one of our vital few of focusing on surgeon confidence with the procedure, the papers that we talked about, we take a very global approach with that. One of the key papers that came out was actually authored by a U.S. doctor, a prominent doctor in Europe as well as in China. So you'll continue to see us take a very global approach. We understand that we are a global company and that we need to make sure that we're hitting all the KOLs globally in order to move the heat on those key geographies.

Thank you. And our next question today comes from Stephen Lichtman with Oppenheimer. Please go ahead.

Hi, guys. This is Ron on for Steve. Congrats on the great quarter. Just wanted to ask about some of the other U.S. initiatives you talked about in the investor meeting, like the call center. How are those going and are you still pursuing them? Thanks.

Yeah, no, thank you for the question. Yeah, regarding the call center, again, we had said it was a pilot project. We certainly ran it through a few months of detailing in 24 through the first three months of this year. I think we've learned some things, but we certainly have made a pivot because we believe those dollars are better directed downstream to really surround our practices in a more effective way. So I think the pilot did what it was intended to do, to show us what we could learn, and we took those learnings and now are redirecting dollars more downstream and surrounding our customers with the various tools that we've developed over the last six to nine months. So I would say the pilot did what it needed to do. It educated us, but we've made a decision to pivot and direct those dollars in a more impactful way. As we said, we want to invest where investments are going to be rewarded, and we think more downstream support of our customers will bear the fruit and certainly begin to bear itself out in the Q1 results.

Thanks a lot. And then I was hoping you guys can provide some color on the gap between the sales growth and the unit growth between different countries and maybe how to reconcile that 9% sales versus 2% units growth towards the small decline in gross margin. Thanks.

Yeah, the gross margin, we'll be fine on that one. There were some inventory adjustments that we cleaned up some prior products that we no longer have on our, that we actually sell. Relations to sort of the difference between revenue and units. Look, we're getting some pretty good economics driven by China specifically, and that's really the one that's pushing the most. I would expect as we go into next year, we'll call it, you'll start seeing that gap. not be as wide anymore, just because the COPs right now are working off the last year's numbers from an ASP standpoint. So we haven't taken a pulse increase in quite some time, and so that's always on the table, and we'll continue to think about that as we move not only through this year, but as we move forward into next year.

Thank you. This concludes our question and answer session. I'd like to turn the conference back over to management for any closing remarks.

Yeah, no, I want to thank you for joining us, and we'll look forward to keeping you updated on our progress.

Thank you. This concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines and have a wonderful day.