Scleral Icterus - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Most people are usually familiar with the medical term jaundice. Scleral icterus is nothing but yellowing of the eyes caused due to various medical conditions like jaundice. The yellowing of the sclera of the eyes is due to increased bilirubin levels in the body.

What Causes the Yellowing of the Eyes?

Increased bilirubin levels in the body can cause the yellowing of skin and mouth, including the eyes. Bilirubin is a yellowish pigment produced by the body as a byproduct during the breaking down of red blood cells (hemolysis). The liver removes the bilirubin from the blood and excretes it as bile in the feces. However, some underlying medical conditions or liver problems (viral hepatitis) can cause bilirubin levels in the blood to rise.

Yellowing of the eyes is due to the accumulation of the yellowish pigment in the conjunctiva (the layer that covers the sclera) and not the sclera (the white portion of the eye). Hence, some medical professionals often term scleral icterus as conjunctival icterus. However, some believe it is the yellowish pigmentation of the scleral tissues of the eye and hence the term scleral icterus.

Jaundice and icterus are no different. Both these conditions refer to yellowing of the eyes due to increased bilirubin levels. Some researchers consider jaundice, a complication of liver disorders and icterus due to systemic jaundice.

What Are the Causes of Scleral Icterus?

Scleral icterus can indicate the initial signs of an underlying condition. It can also occur as an initial symptom of systemic jaundice. However, there could be times when only scleral icterus occurs. Scleral icterus could occur on its own in the case of:

• Subconjunctival hemorrhage produces an excess amount of bilirubin at the injury site (similar to yellow bruising).

• Choroidal hemorrhage following eye surgery.

Normal bilirubin levels are one milligram per deciliter (mg/dL). Scleral icterus occurs when the levels are between two to three milligrams per deciliter (mg/dL). At times medical professionals may misdiagnose the yellowing of the eyes for scleral icterus. However, it could also be the subconjunctival fat that results in a yellow hue. Scleral icterus also affects the area near the corneal tissues.

Causes of scleral icterus are different among different age groups; they vary on the age of the person -

In Infants and Babies

• Physiologic Jaundice - The most common cause is physiologic jaundice which usually occurs in newborns ( first week of birth).

• Breastmilk Jaundice - They can also develop breast milk jaundice due to factors present in the breast milk causing increased absorption of bilirubin from the intestines.

• Hereditary - Inherited diseases like Gilbert’s disease and Crigler-Nijaar syndrome also lead to fluctuations in the bilirubin levels in the body and can lead to scleral icterus.

• Viral Hepatitis - Viral hepatitis is the most severe form of the disease that causes scleral icterus in children (infected liver cells cause improper absorption of bilirubin, leading to accumulation of bilirubin in the blood).

In Elderly

• Obstructive Jaundice - Obstruction of bile ducts can commonly cause scleral icterus in adults. Obstruction of bile ducts can occur as a result of gallstones or malignancy. Other causes include pancreatic cancer and cholangiocarcinoma. Inflammation of the gall bladder (cholecystitis) can also sometimes obstruct the bile flow leading to scleral icterus.

• Liver Dysfunction - Damage to liver cells can cause liver functional impairment. This leads to improper absorption of bilirubin and tends to accumulate in the blood, causing scleral icterus. Alcoholic liver cirrhosis, non-alcoholic liver cirrhosis, viral hepatitis, and drug-induced liver diseases are some causes of scleral icterus in adults.

What are the Symptoms of Scleral Icterus?

The scleral icterus is when the eyes start to have a yellowish hue. However, scleral icterus will not cause symptoms but is rather a symptom of jaundice.

Scleral icterus can occur because of increased bilirubin levels, and one may experience different symptoms that appear along with scleral icterus. Symptoms that may occur along with scleral icterus include:

• Itchy skin.

• Joint pains.

• Fullness in the stomach.

• Fatigue and dullness.

• Malaise.

• Fever.

• Changes in urine or stool.

• Loss of appetite.

• Nausea.

• Sudden weight loss.

• Yellowing of the skin.

• Pale skin.

• Yellowing of eyes.

How Is Scleral Icterus Diagnosed?

Medical professionals start with complete physical and medical history followed by multiple tests to diagnose the condition. The person may have to undergo routine blood and liver function tests to check for liver abnormalities and disorders. Tests may also include serum bilirubin levels to diagnose jaundice. Signs and symptoms are checked for, and complete medical history, including the history of drugs, alcohol, use of toxic substances, hepatitis (inflammation of liver), HIV status, genetic disorders, duration of jaundice, and other medical conditions, are noted and taken into consideration.

What Is the Treatment for Scleral Icterus?

Though there is no definitive treatment for scleral icterus or jaundice, treatment does depend on the underlying medical conditions. Symptoms usually subside after treatment for the underlying cause of jaundice (depending on the liver disorder). The prognosis of scleral icterus due to the resorption of hematomas or Gilbert syndrome (genetic liver disorder) is usually better than other liver disorders like liver cirrhosis. Studies also show the primary way to treat yellow eyes or scleral icterus is to treat the underlying cause as well as maintain a healthy diet to help in faster recovery. Doctors recommend having more fruits and a high fiber diet to help with faster healing.

When jaundice is caused by infections like hepatitis or malaria, it is usually treated with an antibiotic, antifungals, or antiviral medications. Alcohol-induced or drug-induced jaundice may need additional medical assistance to help with quitting the habits. Jaundice resulting from organ damage or as a result of anemia, injuries, cirrhosis, blockage, or cancer may require extensive treatments like surgeries, transplants, chemotherapy or radiation therapies, and at times also, blood transfusions. Neonatal jaundice is usually resolved by increasing breastfeeding sessions to eight to twelve times a day. This helps to improve digestion and helps in bilirubin excretion faster.

Conclusion

Serum bilirubin levels above the normal range indicate scleral icterus. Though scleral icterus does not require treatment, treatment for underlying jaundice can help treat scleral icterus. However, one should seek medical help and consult an ophthalmologist if they start noticing yellowing of eyes at the earliest. This will help the doctors to diagnose the condition and seek the proper and correct treatment.