In this chapter, we review the history of a surgical procedure not generally performed by ophthalmologists, and never performed on the eye, but surprisingly close to the eye.

Transorbital lobotomy was one of the most controversial surgeries ever performed. Frontal leucotomy, intended to sever white matter fibers in the frontal lobe to treat psychiatric disease, was first proposed by Portuguese neurologist Antonio Caetano de Abreu Freire de Resende, also known as Egas Moniz (1874-1955), in 1935 (1). Moniz won the Nobel Prize in 1949 for this work (2). Moniz and neurosurgeon Almeida Lima (1903-1985) initially injected absolute alcohol, and then developed a wire loop called a leucotome, introduced through burr holes in the frontal skull, to sever the fibers. Starting in 1936 in the US, neurologist Walter Freeman (1895-1972) and neurosurgeon James Watts (1904-1994) adapted this technique into what they called prefrontal lobotomy (1).

During this period, neurosurgeons led by American Walter Dandy (1886-1946) debated transorbital versus transcranial approaches for a variety of intracranial diseases. Transorbital surgery is defined as accessing the skull base through an orbital bone without removing or damaging the orbital rim. In 1874, German-American ophthalmologist Herman Knapp (1832-1911) reported anterior orbitotomy to resect an optic nerve sheath “carcinoma.” In 1886, Swiss surgeon Rudolf Kronlein (1847-1910) reported lateral orbitotomy (the “Kronlein operation”) to resect an orbital dermoid cyst. However, Kronlein did not use orbitotomy to access the brain. In 1913, American neurosurgeon Charles Frazier (1870-1936) described a craniotomy through the supraorbital ridge to access the sella turcica region (3).

In 1937, Italian psychiatrist Amarro Fiamberti (1894-1970) reported transorbital lobotomy. Patients were treated with general anesthesia and supplemental procaine (novocaine) injection into the upper eyelid. A guide needle containing a stylet was introduced through the skin (anterior to the upper eyelid) and through the orbital roof 3 cm lateral to the glabella. Once in position, the stylet was removed and the leucotome was passed through the guide needle. The leucotome was expanded and rotated to sever white matter fibers six times in each frontal lobe. In a series of “approximately eighty” patients treated with this technique, no significant eye injuries were reported, other than occasional superficial hemorrhages caused by the anesthetic injections (4).

In 1946, Freeman adapted Fiamberti’s transorbital technique to develop a faster, less invasive procedure that could be performed on patients in overcrowded public mental hospitals lacking operating rooms, neurosurgeons, and anesthesiologists (1). Freeman’s technique could be performed in around five minutes (5). Two important modifications included the use of electroconvulsive therapy to sedate the patient and introduction of the instrument through the palpebral conjunctiva, rather than through the skin. Freeman’s first transorbital patient, Sallie Ellen Ionesco (1917-2007), had a diagnosis of depression and had previously attempted to murder her child and then commit suicide. Following the procedure, she was described as “nonviolent” and “living a relatively normal life” until her death 61 years later. Encouraged, Freeman traveled throughout America performing transorbital lobotomies, often with news reporters in attendance. In at least one case, the patient died during the procedure while the journalists watched (6).

Freeman is estimated to have performed almost 4,000 transorbital procedures in the US (7). Worldwide, an estimated 60,000 transorbital lobotomies were performed, in settings including asylums, outpatient clinics, and, in some extreme cases, motel rooms (7). In Japan, Sadao Hirose (1918-2007) performed an alternative technique that he called “orbital undercutting” (1).

Although there were some successful treatments, the overall outcomes were disappointing, and the technique was criticized by many physicians. Reported complications of lobotomies (both prefrontal and transorbital) included seizures, chronic headache, “frontal lobe syndrome,” and a mortality rate possibly approaching 5% (2). Many physicians viewed the transorbital approach, performed by psychiatrists without aseptic technique, as riskier than the prefrontal approach. Notably, Freeman’s partner, Watts (a neurosurgeon) did not agree with the transorbital technique and ended his collaborations with Freeman by 1950 (6).

Public opinion gradually turned against lobotomy procedures, both transorbital and prefrontal. A famous example was Rosemary Kennedy (1918-2005), a sister of future US President John F. Kennedy, who worsened following prefrontal lobotomy by Freeman and Watts in 1941. In the 1962 novel (and 1975 film) One Flew Over the Cuckoo’s Nest, the main character is subjected to an involuntary lobotomy with a poor outcome. In the novel, a transorbital lobotomy is performed, although this was changed to a prefrontal lobotomy for the film (8).

Lobotomy procedures peaked in popularity in the mid-1950s. The first antipsychotic medication, chlorpromazine (Thorazine), was introduced in 1952 in France (2) and in 1955 in the US (5), with pharmaceuticals eventually replacing surgery for the majority of these patients.