In developed countries, safety standards, monitoring requirements, the availability of drugs and supplies, as well as an adequate supply of well-trained anesthesia providers are such that anesthesia-related mortality is extremely low—less than 1 in 100,000 in the USA [5]. By contrast, in developing countries, deaths attributable to anesthesia in the range of 1 in 133 [6], 1 in 144 [7], and 1 in 504 [8] have been reported. To maintain a safe level of care, basic intraoperative monitoring should include means to assess oxygenation, ventilation, and circulation. Since 2007, the WHO, together with the World Federation of Societies of Anaesthesiologists (WFSA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and others have supported the Global Oximetry Initiative to advocate the provision of pulse oximetry as a minimum monitoring standard during the provision of anesthesia [9]. Pulse oximetry offers the benefit of establishing a basic measure of adequacy of tissue perfusion and oxygenation as well as providing a continuous display of heart rate. When general anesthesia is administered, continuous capnography is the gold standard for ensuring correct placement of the airway and adequacy of ventilation. An esophageal or precordial stethoscope provides an alternative means of assessing adequacy of ventilation when capnography is not available. The WFSA has published recommendations on international standards for the safe practice of anesthesia based on available levels of infrastructure (basic, intermediate, optimal) [10]. This includes suggested minimum drug requirements (Table 15.2). The WHO also has a Model List of Essential Medicines [11].

For ophthalmic procedures, maximizing the use of local and regional anesthesia offers the benefit of minimizing equipment and monitoring needs. It is therefore an ideal approach for the majority of cases. It should be recognized that although it is possible for a visiting medical mission group to transport disposable supplies and drugs, the team will often be dependent on the host nation for daily sterilization of equipment. Therefore, the quality of this sterilization equipment may be a limiting factor in terms of case turnover. It is advisable to provision supplies for at least a full day of surgical procedures without needing to re-sterilize equipment. Carrying disposable back-up instruments can also provide a safety net in the event reusable instruments become unavailable.

In some countries, traditional NPO guidelines are circumvented, especially for those patients who are only expected to receive regional ophthalmic blocks or “minimal” sedation [12]; however, this practice is controversial, and following the ASA Practice Guidelines on Preoperative Fasting is the safest approach (Table 15.3) [13].

As with any anesthetic, it is useful to utilize a pre-anesthetic checklist to ensure that basic preoperative patient information and the necessary anesthesia equipment is available prior to the start of each case (Table 15.4 and Fig. 15.1).

Topical local anesthesia and regional orbital blocks may be employed for most intraocular and periorbital procedures. The increased use of phacoemulsification for cataract extraction has led to a greater use of topical anesthesia for cataract surgery, while most vitreoretinal procedures require a denser anesthesia provided by regional blocks [14]. Among the regional techniques available are the retrobulbar, peribulbar, and sub-Tenon’s block. Relative contraindications to regional ophthalmic block include blindness in the contralateral eye, significant myopia, elevated IOP, and trauma or perforation of the globe [15]. Whether these blocks are performed by an anesthesiologist or ophthalmologist varies by institution and experience of the provider. Regardless, it is the responsibility of the anesthesiologist to monitor the patient’s vital signs during the performance of any regional anesthetic.