Anecortave acetate in age-related macular degeneration Figure 3 The counter pressure device prevents reflux of anecortave acetate when placed as posterior as possible in position with the posterior juxtascleral depot cannula. Posterior juxtascleral depot (PJD) Topical ocular administration and subconjunctival administrations of anecortave acetate did not achieve sufficient concentration of the drug to inhibit angiogenesis in the retina and choroid. Intravitreal injections of anecortave acetate provide therapeutic levels of the drug to the retina; however, routine intravitreal injections were undesirable due to the potential for serious complications such as endophthalmitis and retinal detachment and overall discomfort of the patient. Sub-Tenon’s injections with a straight needle were found to provide therapeutic drug concentrations (≥0.1 uM) in both the retina and choroid, but these injections were highly variable in their placement. Poor drug positioning would result in an undesirably high incidence of treatment failures due to low drug bioavailability; therefore, a specialized cannula and depot delivery technique were developed for the administration of RETAANE. A 56-degree curved posterior juxtascleral cannula was developed to follow the curvature of the globe during insertion, underneath the conjunctiva and Tenon’s capsule, on bare sclera. It has a length that positions the tip directly behind the macula when it is fully inserted. The globe is not perforated during the procedure. The orifice of the cannula is located on the inferior surface of the tip to assure administration of anecortave acetate in direct apposition to the scleral surface (Figure 3). In contrast to the traditional sub-Tenon’s injections which missed the targeted area nearly 30% of the time, Clinical Interventions in Aging 2006:1(3) injections using posterior juxtascleral depot (PJD) delivered the entire dose over the macular region and directly onto the scleral surface. PJD administration results in no risk of endophthalmitis, retinal detachment, or IOP increase because the globe is not penetrated during administration. In clinical studies PJD resulted in no clinically relevant treatment-related adverse events and due to our current knowledge, re-administration of anecortave acetate is only required every 6 months. In the clinical studies it has been shown that anecortave acetate can reflux out the cannula incision during the PJD procedure. To address this issue, a counter pressure device (CPD) has been developed by the manufacturer of the drug to stop the reflux of the suspension, ensuring that the complete quantity of drug is delivered behind the macula. The CPD is positioned as posterior as possible from the incision site, perpendicular to the globe. The notch on the CPD straddles the cannula over the conjunctiva, which allows the procedure to be completed by one person and Table 4 Percentages of adverse events attributed to the posterior juxtascleral administration or sham procedure Anecortave Sham acetate group groups Ptosis Ocular pain Subconjunctival hemorrhage Ocular pruritis 20% 20% 13% 13% 20% 17% 17% 27% 241