Yellowing of the Sclera: Causes, Symptoms, and Treatment

What is Yellowing of the Sclera?

The sclera is the white part of the eye that surrounds the iris (the colored part). When the sclera turns yellow, it is often a sign of an underlying medical condition. This yellowing, medically known as scleral icterus, typically indicates a buildup of bilirubin—a yellow pigment produced during the breakdown of red blood cells—in the body. While it can be alarming, yellowing of the sclera is usually a symptom of another issue rather than a disease itself.

Bilirubin is normally processed by the liver and excreted through bile. When the liver is not functioning properly, or when there is an excess of bilirubin, it can accumulate in tissues, including the sclera, leading to a yellow appearance. This condition is often associated with jaundice, where the skin and whites of the eyes take on a yellowish hue.

Common Causes

Yellowing of the sclera can result from various conditions, most of which involve the liver, blood, or bile ducts. Below are some of the most common causes:

1. Liver Diseases

• Hepatitis: Inflammation of the liver, often caused by viral infections (Hepatitis A, B, or C), alcohol abuse, or autoimmune diseases. The liver’s inability to process bilirubin leads to its buildup in the body.
• Cirrhosis: Scarring of the liver tissue due to long-term damage from conditions like chronic alcoholism, hepatitis, or fatty liver disease. This scarring impairs liver function.
• Fatty Liver Disease: Accumulation of fat in the liver, which can progress to inflammation (steatohepatitis) and liver damage.

2. Bile Duct Obstruction

• Gallstones: Hardened deposits in the gallbladder that can block the bile ducts, preventing bilirubin from being excreted.
• Biliary Strictures: Narrowing of the bile ducts due to scarring, inflammation, or tumors, which can obstruct bile flow.
• Pancreatic Cancer: Tumors in the pancreas can press on the bile ducts, causing a blockage.

3. Hemolytic Anemia

This condition occurs when red blood cells are destroyed faster than the body can replace them, leading to an excess of bilirubin. Causes include:

• Autoimmune disorders (e.g., autoimmune hemolytic anemia)
• Genetic conditions (e.g., sickle cell anemia, thalassemia)
• Infections (e.g., malaria)
• Reactions to certain medications or blood transfusions

4. Gilbert’s Syndrome

A mild, inherited liver condition where the liver doesn’t properly process bilirubin. It often causes mild jaundice, especially during stress, illness, or dehydration, but it is not harmful.

5. Newborn Jaundice

Common in newborns, this occurs because a baby’s liver is not fully developed and may struggle to process bilirubin. It usually resolves on its own but may require treatment if severe.

6. Medications and Toxins

Certain medications and substances can cause liver damage or interfere with bilirubin processing, including:

• Acetaminophen (Tylenol) overdose
• Alcohol abuse
• Some antibiotics, anticonvulsants, or chemotherapy drugs
• Toxins like poisonous mushrooms or industrial chemicals

7. Infections

Infections that affect the liver or bile ducts can lead to yellowing of the sclera, such as:

• Mononucleosis (Epstein-Barr virus)
• Cytomegalovirus (CMV)
• Leptospirosis (a bacterial infection)

8. Metabolic Disorders

Rare genetic disorders that affect bilirubin metabolism, such as:

• Crigler-Najjar syndrome
• Dubin-Johnson syndrome

Associated Symptoms

Yellowing of the sclera is often accompanied by other symptoms, depending on the underlying cause. Common associated symptoms include:

• Yellowing of the skin (jaundice): Often the first noticeable sign, especially in lighter-skinned individuals.
• Dark urine: Bilirubin in the urine can make it appear dark yellow or brown.
• Pale or clay-colored stools: A lack of bilirubin in the stool can cause it to lose its normal brown color.
• Fatigue and weakness: Common in liver diseases and anemia.
• Abdominal pain or swelling: May indicate liver enlargement, gallstones, or bile duct obstruction.
• Nausea and vomiting: Often seen in hepatitis, gallstones, or liver dysfunction.
• Fever or chills: May accompany infections like hepatitis or biliary tract infections.
• Itchy skin (pruritus): Common in bile duct obstructions due to the buildup of bile salts in the skin.
• Loss of appetite or unintended weight loss: Can occur in chronic liver disease or cancer.
• Easy bruising or bleeding: The liver produces clotting factors, so liver damage can lead to bleeding issues.

If you notice yellowing of the sclera along with any of these symptoms, it is important to seek medical evaluation to determine the cause.

When to See a Doctor

Yellowing of the sclera should never be ignored, as it often signals an underlying health issue that may require treatment. You should schedule an appointment with your healthcare provider if:

• The yellowing is new or worsening.
• You experience accompanying symptoms like dark urine, pale stools, abdominal pain, or fatigue.
• You have a history of liver disease, alcohol abuse, or exposure to hepatitis.
• The yellowing persists for more than a few days, especially in adults.

For newborns, contact a pediatrician if:

• Jaundice appears within the first 24 hours of life.
• The yellowing spreads to the arms, legs, or abdomen.
• The baby is difficult to wake, not feeding well, or seems very irritable.

Diagnosis

To determine the cause of yellowing of the sclera, your doctor will likely perform a combination of the following:

Medical History and Physical Exam

Your doctor will ask about your symptoms, medical history, medications, alcohol use, and potential exposure to hepatitis. They will also perform a physical exam to check for:

• Enlargement or tenderness of the liver or spleen.
• Signs of fluid retention or abdominal swelling (ascites).
• Skin changes, such as spider angiomas (small, spider-like blood vessels) or palmar erythema (reddening of the palms), which can indicate liver disease.

Blood Tests

Blood tests are essential for diagnosing the cause of scleral yellowing. Common tests include:

• Liver function tests (LFTs): Measure levels of enzymes (ALT, AST), bilirubin, albumin, and other substances to assess liver health.
• Complete blood count (CBC): Checks for anemia, infection, or other blood disorders.
• Viral hepatitis panels: Tests for Hepatitis A, B, or C.
• Coagulation tests (PT/INR): Evaluates the liver’s ability to produce clotting factors.

Imaging Tests

Imaging may be used to visualize the liver, gallbladder, and bile ducts:

• Ultrasound: Often the first imaging test to check for gallstones, liver abnormalities, or bile duct obstructions.
• CT scan or MRI: Provides detailed images of the liver and surrounding structures.
• MRCP (Magnetic Resonance Cholangiopancreatography): A specialized MRI to examine the bile and pancreatic ducts.
• ERCP (Endoscopic Retrograde Cholangiopancreatography): A procedure that combines endoscopy and X-rays to diagnose and treat bile duct obstructions.

Liver Biopsy

In some cases, a small sample of liver tissue may be taken for analysis to diagnose conditions like cirrhosis, hepatitis, or cancer.

Treatment Options

The treatment for yellowing of the sclera depends on the underlying cause. Here are some common approaches:

Medical Treatments

• Hepatitis: Antiviral medications (for viral hepatitis), steroids (for autoimmune hepatitis), or supportive care.
• Bile Duct Obstruction:
  • Gallstones may be treated with surgery (cholecystectomy) or ERCP to remove the stones.
  • Biliary strictures may require stent placement or surgical repair.
  • Tumors may be treated with surgery, chemotherapy, or radiation.
• Hemolytic Anemia: Treatment depends on the cause and may include medications to suppress the immune system, blood transfusions, or splenectomy (removal of the spleen).
• Liver Cirrhosis: Focuses on managing complications, such as fluid retention, infections, and bleeding. In severe cases, a liver transplant may be necessary.
• Newborn Jaundice:
  • Phototherapy (light therapy) to help break down bilirubin.
  • Exchange transfusion in severe cases.
• Medication-Induced Liver Damage: Discontinuing the offending medication and supportive care.

Home and Lifestyle Remedies

While medical treatment is often necessary, certain lifestyle changes can support liver health and prevent further damage:

• Avoid alcohol: Alcohol can worsen liver damage, so it’s important to avoid it if you have liver disease.
• Stay hydrated: Drinking plenty of water helps the liver function properly.
• Eat a balanced diet:
  • Focus on fruits, vegetables, whole grains, and lean proteins.
  • Avoid fatty, fried, or processed foods.
  • Limit salt intake to reduce fluid retention.
• Maintain a healthy weight: Obesity can contribute to fatty liver disease.
• Avoid toxins: Be cautious with medications, supplements, and exposure to chemicals.
• Exercise regularly: Physical activity supports overall health and liver function.

Prevention Tips

While not all causes of yellowing of the sclera can be prevented, you can take steps to reduce your risk:

• Get vaccinated: Vaccines are available for Hepatitis A and B. Talk to your doctor about vaccination if you’re at risk.
• Practice safe sex and avoid sharing needles: Hepatitis B and C can be transmitted through bodily fluids.
• Limit alcohol consumption: Excessive alcohol use is a leading cause of liver disease.
• Use medications wisely:
  • Follow dosage instructions carefully, especially for acetaminophen.
  • Avoid mixing medications without consulting your doctor.
• Maintain a healthy diet and weight: This can prevent fatty liver disease and other metabolic conditions.
• Stay hydrated: Proper hydration supports liver and kidney function.
• Practice good hygiene: Wash your hands regularly to avoid infections like Hepatitis A.
• Get regular check-ups: Early detection of liver or blood disorders can prevent complications.

Emergency Warning Signs

Seek immediate medical attention if you experience yellowing of the sclera along with any of the following symptoms, as they may indicate a serious or life-threatening condition:

• Severe abdominal pain, especially in the upper right side, which could indicate a gallbladder attack or liver abscess.
• Confusion, drowsiness, or difficulty waking: Signs of hepatic encephalopathy, a complication of liver failure where toxins build up in the brain.
• Vomiting blood or black, tarry stools: Indicates internal bleeding, which can occur in advanced liver disease.
• Swelling of the abdomen with severe pain or difficulty breathing: Could signal a ruptured organ or severe fluid buildup.
• High fever with chills and jaundice: May indicate a severe infection like cholangitis (bile duct infection).
• Signs of shock, such as rapid heartbeat, low blood pressure, or cold, clammy skin.

If you or someone else experiences these symptoms, call emergency services or go to the nearest emergency room immediately.

Conclusion

Yellowing of the sclera is a noticeable sign that something may be wrong with your liver, bile ducts, or blood. While it can be alarming, many causes are treatable, especially when caught early. If you notice this symptom, don’t ignore it—schedule an appointment with your healthcare provider to determine the underlying cause and receive appropriate treatment. By understanding the potential causes, associated symptoms, and when to seek help, you can take proactive steps to protect your health.

Sources and References

• Mayo Clinic. (2021). Jaundice. www.mayoclinic.org
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2020). Liver Disease. www.niddk.nih.gov
• Cleveland Clinic. (2022). Jaundice in Adults. my.clevelandclinic.org
• World Health Organization (WHO). (2021). Hepatitis. www.who.int
• American Liver Foundation. (2021). Liver Disease Information. www.liverfoundation.org