Scleral Icterus: Causes, Symptoms, Diagnosis & Treatment Explained

Scleral icterus refers to a situation in which the sclera, which is the white part of the eye, turns yellow. Bilirubin in the blood is excessively high and makes the sclera yellow. Bilirubin is a yellowish color that is formed when old or damaged red blood cells are broken down in the body. Typically, it is disintegrated in the liver and excreted in the bile (in the stool).

However, when bilirubin is built up in the body, which is known as hyperbilirubinemia, it begins to build up in the tissues. The first effects of the accumulation to be noticed are the sclera of the eye, as the part of the eye in which there is a substance resembling protein, called elastin, which is highly attractive to bilirubin. As a result, the sclera of the eye becomes yellow, and the rest of the skin becomes yellow.

Types of Scleral Icterus

Pre-Hepatic Icterus (Hemolytic)

Pre-hepatic icterus occurs when red blood cells are destroyed rapidly, as seen in hemolysis. This excessive breakdown overwhelms the liver with unconjugated bilirubin that cannot be processed quickly enough.

Hepatic Icterus (Hepatocellular)

Hepatic icterus is caused by damage to liver cells, impairing their ability to conjugate bilirubin. It is commonly associated with viral infections, toxins, or fatty liver disease.

Post-Hepatic (Obstructive) Icterus

Post-hepatic icterus occurs when bile ducts are obstructed by stones, tumors, or strictures. This prevents the excretion of conjugated bilirubin, causing it to accumulate in the bloodstream.

Gilbert Syndrome

Gilbert syndrome is a mild, inherited condition characterized by occasional increases in unconjugated bilirubin, especially during fasting, stress, or illness. It is generally harmless.

Dubin–Johnson Syndrome

Dubin–Johnson syndrome is a rare genetic disorder involving defective bilirubin transport. It leads to conjugated hyperbilirubinemia but usually does not cause serious health issues.

What Causes Scleral Icterus

The causes of bilirubin accumulating in the body and making the eyes yellow are many. The causes are usually divided into three categories depending on the location of the problem occurring.

Before the liver (pre-hepatic) problems.

Diseases that cause the red blood cells to be destroyed more rapidly than normal may overwhelm the system with bilirubin. Common ones are sickle cell disease, thalassemia, and G6PD deficiency. In such situations, the liver is just not able to cope with the additional burden.

Issues within the liver (hepatic)

Hepatitis A, B, C, and E cause liver inflammation in the cells. This makes it difficult to normally process bilirubin. Cirrhosis also leads to the liver being less efficient since the liver is damaged due to long-term consumption of alcohol or fatty liver disease. Some drugs, like high-dose paracetamol, can cause direct injury to the liver cells. Gilbert syndrome is an inoffensive genetic disorder, where the bilirubin is slightly high on fasting, illness, and stress.

The problems following the liver (post- hepatic )

The presence of gallstones may result in the obstruction of the bile ducts and the rapid accumulation of bilirubin in the blood. Tumors of the pancreas have the ability to press slowly on the ducts and result in painless yellowing of the eyes and loss of weight.

Symptoms That Show Up Along With Scleral Icterus

Yellowing of the Eyes

The whites of the eyes take on a yellow tint due to the accumulation of bilirubin in the bloodstream, which the liver is unable to process efficiently. This is often the earliest visible sign and can gradually become more pronounced as bilirubin levels rise.

Weakness & Fatigue

Many people experience persistent fatigue because the liver is unable to effectively filter toxins from the body. Even simple daily activities can feel exhausting, and this tiredness typically does not improve with rest or sleep.

Upper Right Abdominal Pain

Pain in the upper right part of the abdomen is commonly linked to liver inflammation or gallstones affecting nearby structures. It may present as a dull, lingering discomfort or a sharp pain that becomes more noticeable after eating fatty foods.

Itchy Skin

Itching occurs when bile salts build up beneath the skin due to impaired liver function. This irritation is often deep-seated, worsens at night, and does not get much relief from scratching.

Dark Urine

Urine may appear dark brown or tea-colored as excess bilirubin is excreted through the kidneys. This change in color is often one of the more noticeable systemic signs accompanying jaundice.

Nausea & Loss of Appetite

People may feel nauseated or lose interest in food as the digestive system is affected by liver dysfunction. Even small amounts of food can trigger discomfort, leading to reduced intake over time.

Unintentional Weight Loss

A decrease in appetite combined with ongoing nausea can result in gradual, unintended weight loss. This often reflects the body’s inability to properly process nutrients and maintain energy balance.

Bitter Taste in Mouth

Some individuals report a persistent bitter or unpleasant taste in the mouth. This can be linked to bile imbalance and contributes to an overall feeling of being unwell.

Scleral Icterus Treatment Options

The treatment will solely rely on the cause of the accumulation of bilirubin. Scleral icterus does not have a single solution since it is a symptom of a problem that is not a disease. After treatment of the root cause, the yellowing of the eyes slowly disappears.

• Antiviral drugs like Tenofovir and Entecavir are administered to curb the virus and the inflammation in viral hepatitis in a few weeks or months. Although they do not cure hepatitis B, they suppress the virus, and the liver recovers.
• Newer direct-acting antiviral medications can normally cure hepatitis C within 8-12 weeks. Hepatitis A and E are self-limiting conditions that can be treated through rest and supportive care, yet severe disease can be treated in the hospital.
• Ursodeoxycholic acid can thin bile and dissolve small cholesterol gallstones in mild blockages to enhance the flow of the bile. It is also able to reduce liver disease in such conditions as primary biliary cholangitis.
• Endoscopic retrograde cholangiopancreatography (ERCP) is a method that involves the insertion of a long and flexible tube, equipped with a camera, into the mouth and the small intestine. This allows physicians to reach the bile duct opening and remove stones, place stents to keep the bile duct open, or take tissue samples to analyze.
• The people with hemolytic disorders like sickle cell disease are treated using blood transfusions and folate supplements in case of crisis.
• Sickle cell crisis is usually prevented with the help of hydroxyurea. Steroids or immunosuppressive medications might also be needed in certain severe autoimmune hemolytic anemias to prevent the destruction of the red blood cells by the immune system.

Save Sight Centre's Role in Detecting Scleral Icterus

The ophthalmologists at the Save Sight Centre examine patients' eyes to look for signs of scleral icterus. The yellowing of the eyes can appear earlier than other symptoms, so visiting an eye doctor can help diagnose liver or blood diseases. The centre works with gastroenterologists and hepatologists to ensure timely and appropriate follow-up care for patients.

The centre has its own laboratories capable of performing bilirubin profiling, liver function tests, and full blood counts. It also has an ultrasound, so patients do not need to be transported elsewhere. The tests are processed quickly, which speeds up diagnosis and treatment.

For patients requiring long-term follow-up, the hepatology team at the Save Sight Centre monitors viral loads and treatment responses, especially for hepatitis B and C patients, who need regular blood tests to confirm treatment effectiveness.