Yellowing of the Eyes

What is Yellowing of the eyes?

Anatomically-speaking, the white portion of the eye is known as the sclera. In the situation that there is a health problem in the body, the white portion of the eye is going to turn yellow. The yellowing of the eyes is often accompanied by the yellowing of the skin (jaundice), suggesting that there is a dysfunction in one of the following organs: liver, gallbladder or pancreas. It is possible that more than just one organ is affected.

Why do such changes occur? Well, in healthy individuals, the hemoglobin is broken into bilirubin; this substance reaches the liver and the bile ducts, then being eliminated through the stool. In the situation that there is a dysfunction at the level of the liver or the bile ducts, the bilirubin starts to accumulate at the level of the body, leading to the yellowing of the eyes and the skin.

It is important to remember that, by eating foods that are rich in vitamin A or beta carotene, one can experience the yellowing of the skin. Among these foods, there are carrots, squash and melons. However, this change occurs solely at the level of the skin, without the sclera of the eyes becoming yellow as well.

It is known that one of the first tissues that starts to change its color as the levels of bilirubin rise is the conjunctiva. Even though it is said that the whites of the eyes turn a yellow color, this is not actually accurate. The sclera is not the one that is stained with the yellow bilirubin pigment but rather the conjunctival membrane covering it.

According to the specialists in the field, the yellowing of the eyes and the skin can be classified into three categories (in accordance to the physiological mechanism and the pathology):

• Pre-hepatic/hemolytic
  • Pathology occurring prior to the liver (intrinsic or extrinsic causes)
• Hepatic/hepatocellular
  • Pathology located within the liver (liver disease)
• Post-hepatic/cholestatic
  • Pathology located after the conjugation of bilirubin into the liver (biliary obstruction).

Symptoms of Yellowing of the Eyes

These are the symptoms that are commonly found in association with the yellowing of the eyes:

• Yellowing of the skin (jaundice)
• Loss of appetite
• Nausea and vomiting
• Sudden weight loss
• State of general weakness and fatigue (unexplained)
• Bloody-appearing light-colored stool
• Fever and/or chills
• Abdominal pain (most commonly upper right quadrant)
• Dark urine
• Itchiness at the level of the skin.

The accumulation of excess bilirubin at the level of the central nervous system can lead to serious complications, such as kernicterus. This is a bilirubin-induced brain dysfunction, which can lead to irreversible neurological damage and even death. Newborns present the highest risks for such complications, so their bilirubin level has to be kept under control at all times (increased permeability of the blood brain barrier).

What Causes Yellow Eyes?

These are the most common causes that can lead to the yellowing of the eyes:

Liver disease (cirrhosis)

• Most common causes include:
  • Chronic abuse of alcohol
  • Viral infection (hepatitis – A, B, C, D or E hepatic virus)
  • Other types of infections occurring at the level of the liver
  • Neoplasm
  • Non-alcoholic fatty liver disease (high risk – obesity)
  • Hemochromatosis (excess iron is collected at the level of the liver, with a negative impact on its overall functioning)
  • Wilson’s disease (excess buildup of copper in the liver)
  • Porphyria (excess porphyrin – genetic disorder)
  • Hepatotoxicity
  • Drug-induced hepatitis

Gallbladder disease

• Blockage of bile ducts (gallstones – most common cause of blockage)
• Gallbladder cysts
• Neoplastic growths
• Inflammatory processes

Pancreas disease

• Pancreatic cancer
• Pancreatitis (inflammation of the pancreas)
• Pancreatic pseudocysts

Blood disorders

• Drug-induced immune hemolytic anemia
• Incompatibility reaction with blood transfusion (medical emergency)
• Sickle cell anemia

Genetic disorders

• Spherocytosis
• Thalassemia
• Pyruvate kinase deficiency
• Glucose 6-phosphate dehydrogenase deficiency
• Gilbert’s syndrome (genetic disorder of bilirubin metabolism)
• Crigler-Najjar syndrome (type I and II)

Kidney disease

• Hemolytic uremic syndrome

Other causes

• Neonatal jaundice
• Leptospirosis (rat fever)
• Biliary atresia
• Medication (mepacrine)
• Excessive exposure to phenols
• Severe malaria
• Cholangiocarcinoma
• Cholestasis of pregnancy
• Mirizzi’s syndrome (rare cause).

Diagnosis

These are the most common methods used for the diagnosis of the underlying conditions:

Medical history of the patient

• When did the symptoms appear for the first time
• Similar problems in the past
• Chronic conditions
• Current and past treatments (including surgical interventions)

Physical assessment

• Identification of scleral icterus and skin yellowing
• Palpation of the abdomen
• Weight calculation

Urinalysis

• Presence of bilirubin
• Pre-hepatic jaundice – urobilinogen
• Conjugated bilirubin (hepatic jaundice)
• No urobilinogen → complete obstruction of the bile duct (post-hepatic jaundice)
• Conjugated bilirubin present in the urine + no urobilinogen → obstructive jaundice, intra-hepatic or post-hepatic

Serum analysis

• Increased unconjugated bilirubin (pre-hepatic jaundice)
• Plasma proteins – characteristic changes (hepatic jaundice)
• Plasma albumin levels low (hepatic jaundice)
• Plasma globulins raised → formation of antibodies (hepatic jaundice)
• Elevated serum cholesterol (post-hepatic jaundice)

Other tests

• Stool analysis
  • Pale stool – hepatic or post-hepatic jaundice
• Alkaline phosphatase levels
  • Normal (pre-hepatic jaundice)
  • Increased (hepatic and post-hepatic jaundice)
• Alanine transferase and aspartate transferase levels
  • Normal (pre-hepatic jaundice)
  • Increased (hepatic and post-hepatic jaundice).

Treatment

These are the methods of treatment recommended for the underlying conditions leading to the yellowing of the eyes and skin:

• Bili light
  • Recommended in case of neonatal jaundice
  • The baby is exposed to intense phototherapy
  • Also recommended – sunbathing (promotes the production of vitamin D)
  • Parents are instructed to perform frequent and effective feedings, due to the fact that bilirubin is lowered through the physiological processes of urination and bowel movements
• Intravenous fluids (prevent dehydration)
• Antibiotics (in case of infection)
• Antiemetic medication (in case of nausea)
• Anti-inflammatory medication or analgesics (reduction of inflammation and pain relief)
• Antiviral medication (in case of viral infection – hepatitis)
• Corticosteroids (anti-inflammatory properties; cannot be administered for prolonged periods of time, due to their negative side effects)
• Chemotherapy or radiation therapy (in case of cancer)
• Blood transfusions
• Discontinuance of medication
• Surgical intervention
  • Removal of obstruction (gallstones)
  • Organ transplantation (liver)
  • Removal of neoplastic growth or cyst (if possible)
  • Repair of congenital malformation

Pictures