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Background and Aims The mitochondrial disease (chronic progressive external ophthalmoplegia with myopathy) poses many challenges to the anesthetists as eyelid ptosis can be isolated or associated with laryngeal and respiratory muscles affections.

Methods We present a case a-47-year old female with CPEO with myopathy evaluated in anesthesia clinic for Laparoscopic subtotal hysterectomy, she had in addition to eyelid ptosis, difficulty swallowing and choking with liquids, nasal speech and weakness in her arms and pain cramps in her legs. She is also diabetic and hypertensive. Neurological consultation was done with recommendations to avoid paralytic agents and certain mitochondrial metabolized medications. Cardiac and IM consultation was carried out. The impact of her condition on anesthetic approach was discussed with the gynecologist and regional anesthesia was strongly recommended over general Anesthesia. Hence the patient was counseled, and the procedure was changed to Laparotomy under CSE. The full anesthetic techniques were fully explained to the patient.

Results The intra-operative and postoperative remained uneventful and the patient shifted to PACU pain free.

Conclusions CPEO with myopathy present limitations to anesthetists. Choosing regional anesthesia with sedation gave a wide range of safety and made the challenging cases easier. Close communication and collaboration between the surgeon and anesthesiologist are essential to ensure the safe and optimal management of such cases.