Scleral Icterus: Causes, Symptoms & Treatment

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What is Scleral Icterus?

Scleral icterus describes the yellowing (jaundice) of the eyes. Different, underlying medical conditions can cause the eyes to take on this color. However, the increase in bilirubin levels triggered by these conditions leads to the characteristic yellow hue. 

Bilirubin is a yellow-like pigment that your body produces when it breaks down red blood cells. Your liver is responsible for pulling the bilirubin from your blood and changing its composition to pass the substance through feces as bile. 

However, if you have liver problems or other health-related issues, bilirubin levels can rise. Viral hepatitis is an example of a medical condition that can prevent the liver from performing correctly. 

Scleral icterus will often occur when your bilirubin levels are between 2-3 mg/dL. This does not mean that your skin or other mucous membranes have also become yellow. Jaundice could only affect the eyes.

When bilirubin levels continue going up, though, you face the risk of jaundice spreading throughout the body. 

Scleral icterus may not require treatment. It will depend on the cause. Nonetheless, you should speak with your healthcare provider to undergo tests and a physical examination. Your doctor will be able to perform a diagnosis and rule out any possible health problems.  

Scleral icterus is a common medical term to refer to jaundice in the eyes. However, bilirubin does not accumulate in the sclera (white part of the eye). The yellowish pigment instead builds up in the conjunctiva (tissue covering the sclera). Scleral icterus is not the right word to describe the condition. Instead, conjunctival icterus would be the correct naming.  

What is the Difference Between Icterus and Jaundice?

There is no distinct difference between icterus and jaundice. Both terms refer to the yellowing of the eyes, skin, and/or mucous membranes due to elevated levels of bilirubin. 

However, semantics could cause some to believe there are differences.

Some health professionals may consider jaundice (from the French root word “jaune” for yellow) as a complication because of an underlying health issue. Icterus, for example, could be a sign of systemic jaundice to come. 

Regardless, if you develop yellowing of the eyes or other body areas, you should speak with your healthcare provider. You may require treatment for an undiagnosed health problem. 

Hepatitis A is the most frequent cause of jaundice in children. 

What Causes Jaundice? What Does it Look Like? 

You can develop jaundice when your bilirubin levels go above normal. Another word used for jaundice is icterus or hyperbilirubinemia. The normal serum levels of bilirubin are less than 1 mg/dL. 

That said, the higher the levels, the more pervasive jaundice is in the body. 

An accumulation of excess bilirubin happens when your body cannot excrete the pigment efficiently, or you produce too much of the pigment. Jaundice can be progressive, affecting first the eyes before transitioning over to other areas of the body. 

Skin color can take on a lemon-yellow-to-apple-green shade, especially if it is long-lasting. The green color is attributable to biliverdin (a pigment that comes from your body breaking down heme—an iron-containing compound in red blood cells). 

The following list contains different conditions and syndromes that can cause jaundice:

  • Dubin-Johnson syndrome
  • Rotor syndrome
  • Hepatocellular diseases, including viral hepatitis A, B, D; alcoholic hepatitis; cirrhosis, non-alcoholic steatohepatitis, Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), Wilson disease, and various autoimmune diseases
  • Cholestatic liver disease
  • Sepsis and hypoperfusion states
  • Total parenteral nutrition (administered elsewhere in the body than the mouth or alimentary canal)
  • Drugs and toxins, including oral contraceptives, rifampin, probenecid, steroids, chlorpromazine, herbal medications, arsenic
  • Hepatic crisis in sickle cell disease
  • Pregnancy
  • Choledocholithiasis (gallstones in the bile duct)
  • Tumors, such as cholangiocarcinoma
  • Extrahepatic biliary atresia
  • Acute and chronic pancreatitis (inflammation of the pancreas)
  • Strictures (abnormal narrowing of a body passage)
  • Parasitic infections, such as liver flukes
  • Hemolytic anemias (Abnormal destruction of red blood cells)
  • Extravasation of blood in tissue (leakage of blood into tissue)
  • Dyserythropoiesis (abnormal development of red blood cells)
  • Gilbert syndrome 
  • Crigler–Najjar syndrome type 1 and 2
  • Hyperthyroid
  • Estrogen

What Causes Scleral Icterus?

Scleral icterus is the jaundice of the eyes. It can indicate the initial signs of an underlying condition. It can also precede systemic jaundice, in which yellowing of other body areas occurs. 

If you develop scleral icterus, you will have above-normal bilirubin levels (normal levels are 1 mg/dL). Scleral icterus happens when serum bilirubin levels are between 2-3 mg/dL. 

Interestingly, some health providers may misdiagnose the yellowing of the eyes for scleral icterus. You could have prominent subconjunctival fat that results in the yellow hue. A distinguishing feature of scleral icterus is that jaundice also affects the area near the cornea. 

Scleral icterus could represent the only sign of jaundice on physical examination in people with dark skin color. 

What are the Symptoms of Scleral Icterus?

Scleral icterus refers to when your eyes become yellow. However, scleral icterus will not cause symptoms. Rather, symptoms are related to the underlying cause of jaundice.

Scleral icterus can occur because of increased bilirubin levels due to an underlying health issue

In other words, you may have different symptoms that appear alongside scleral icterus. You should be aware of these symptoms and alert your doctor. A proper diagnosis will depend on a physical examination plus all symptoms present.

Possible symptoms you may have while with scleral icterus include:

  • Itchy skin
  • Joint aches
  • Fullness in the stomach
  • Fatigue
  • Malaise
  • Fever
  • Changes in urine or stool
  • Loss of appetite
  • Nausea
  • Sudden weight loss

Yellowing of the skin does not always mean that you have jaundice. If you do not develop scleral icterus, are healthy, and your skin turns yellow, you could have carotenoderma. This condition occurs when you follow an excessively carotene-rich diet (e.g., eating a lot of carrots). 

How is Scleral Icterus Diagnosed?

To determine the cause of scleral icterus, your healthcare provider will perform multiple tests. You will undergo liver function tests to evaluate any possible impairments in the organ. Your doctor may also perform a physical examination and ask you about any recent signs or symptoms. 

Furthermore, your doctor may ask a comprehensive series of questions related to:

  • Use of drugs, alcohol, or other toxic substances
  • Risk factors for hepatitis, e.g., unsafe sexual practices
  • HIV status 
  • Family history of genetic disorders or hemolytic disorders 
  • Duration of jaundice 

All of these details will help your doctor rule out various health conditions and reach a proper diagnosis

How is Scleral Icterus Treated? 

There is no direct treatment for either scleral icterus or jaundice. Treatment options will depend on the underlying disease or health problem causing the yellowing of the eyes and/or skin. 

Conversely, the prognosis of scleral icterus or jaundice will vary based on the cause. For example, jaundice due to resorption (absorption into the circulation of cells or tissue) of hematomas or Gilbert syndrome (genetic liver disorder) will have a better prognosis than that of malignant biliary obstructions and liver cirrhosis (scarring to the liver caused by long-term damage).

Resources
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Adult Jaundice: Symptoms, Causes, Diagnosis, Treatment & Prevention.Cleveland Clinic, 23 July 2018.

Beisel, Bert. “Use of the Term Conjunctival Icterus Instead of Scleral Icterus.Letters to the Editor, American Family Physician, 1 Jan. 2005.

Joseph, Abel. “Jaundice.StatPearls [Internet]., U.S. National Library of Medicine, 18 July 2021.

McGee, Steven. “Jaundice.Evidence-Based Physical Diagnosis (Fourth Edition), Elsevier, 23 Feb. 2017.

Mortensen, Zachary Q. “Icterus/Jaundice.EyeRounds, University of Iowa Health Care, 3 Mar. 2020.

Tooley, Andrea A, and Seth Sweetser. “Clinical Examination: Eyes.” AASLD, John Wiley & Sons, Ltd, 28 June 2016.

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