Yellow Eyes (Scleral Icterus)

Why the eyes turn yellow

Bilirubin is a yellow pigment made when old red blood cells are broken down. The liver processes it and sends it out in bile through the bile ducts into the gut, which is why stool is brown. Jaundice develops when:

1. Too much bilirubin is made (red blood cells break down too fast)
2. The liver cannot process it (liver cell damage or enzyme problems)
3. Bile cannot drain (blocked bile ducts)

The sclera contains elastin, which binds bilirubin, so the eyes yellow before the skin does. Yellow eyes are often easiest to see in natural daylight.

Causes of yellow eyes

Liver disease

• Hepatitis: viral hepatitis A, B, C and E, alcohol-related hepatitis and autoimmune hepatitis. Often with tiredness, nausea and upper right belly ache.
• Alcohol-related liver disease and cirrhosis: yellow eyes alongside a swollen belly, easy bruising, spider veins and confusion in advanced disease.
• Fatty liver disease: usually causes jaundice only when advanced.
• Medicines and supplements: acetaminophen overdose, some antibiotics (amoxicillin-clavulanate), anti-seizure medicines, statins rarely, and herbal and bodybuilding supplements.
• Inherited conditions: hemochromatosis, Wilson disease.

Blocked bile ducts

• Gallstones in the common bile duct cause jaundice with episodes of upper right belly pain. Add fever and chills and it may be cholangitis, an emergency.
• Pancreatic cancer: painless jaundice with dark urine, pale stools, itching and weight loss, usually over 50.
• Bile duct cancer and primary sclerosing cholangitis.
• Pancreatitis with swelling around the duct.

Red blood cell breakdown

• Hemolytic anemia: from inherited conditions (sickle cell disease, hereditary spherocytosis, G6PD deficiency), autoimmune disease, infections or some medicines. Urine is usually normal color, and you may feel tired and breathless.
• Malaria in travelers.

Gilbert syndrome

Gilbert syndrome is a common, harmless inherited condition in which the liver processes bilirubin more slowly. Mild yellowing of the eyes appears during fasting, illness, stress, dehydration or heavy exercise and fades on its own. Liver function is otherwise normal. It affects around 1 in 20 people.

Newborn jaundice

Many healthy newborns develop yellow skin and eyes in the first week as their liver matures. Most cases are mild, but high levels can harm the brain, so babies are checked before leaving hospital and in the first days at home.

Yellow eyes that are not jaundice

• Pinguecula: a yellowish, slightly raised spot on the white of the eye beside the cornea, caused by sun and wind exposure. It does not affect the whole sclera.
• Subconjunctival hemorrhage fading: a broken blood vessel can turn yellow-green as it heals.
• Carotenemia: eating large amounts of carrots or sweet potatoes turns the skin, especially the palms, orange-yellow but leaves the eyes white.
• Natural pigmentation: some people, particularly with darker skin, have a slightly brown or muddy tinge to the sclera that is normal.

Clues from other symptoms

How doctors find the cause

A doctor will ask about alcohol, medicines and supplements, travel, sexual history and injecting drug use (hepatitis risks), family history, and symptoms such as pain, fever, itching and weight loss.

Tests usually include:

• Liver function tests: total and direct bilirubin, ALT, AST, alkaline phosphatase, GGT, albumin
• Blood count and markers of hemolysis
• Clotting test (INR): shows how well the liver is working
• Hepatitis virus tests
• Ultrasound of the liver and bile ducts, the first imaging test for blockage
• CT, MRCP or ERCP to look at the bile ducts in detail and, with ERCP, remove stones
• Liver biopsy occasionally

Treatment

Yellow eyes improve when the underlying cause is treated:

• Blocked bile duct: removing stones by ERCP, placing a stent, and gallbladder removal
• Viral hepatitis: supportive care, or antiviral medicines for hepatitis B and C
• Alcohol-related liver disease: stopping alcohol completely, nutrition support, and sometimes steroids
• Medicine-induced liver injury: stopping the drug
• Hemolysis: treating the cause, folic acid, and sometimes transfusion
• Gilbert syndrome: no treatment needed
• Newborn jaundice: phototherapy if levels are high

Itching from jaundice can be eased with cool showers, fragrance-free moisturizers and prescribed medicines.

Frequently asked questions

What do yellow eyes mean?

Yellow eyes usually mean jaundice, a buildup of bilirubin in the blood. It is caused by liver disease, blocked bile ducts, rapid breakdown of red blood cells, or harmless Gilbert syndrome. New yellowing of the eyes in an adult should be checked with blood tests.

Are yellow eyes serious?

They can be. Yellow eyes can signal hepatitis, gallstones, liver damage from alcohol or medicines, or, less often, cancer. Mild, intermittent yellowing in an otherwise healthy person may be Gilbert syndrome. Because the causes vary so much, any new jaundice needs a medical assessment.

What does yellow eyes and dark urine mean?

Yellow eyes with dark, tea-colored urine mean bilirubin is being cleared through the kidneys, which happens when the liver cannot process it or bile is blocked. This points to hepatitis, liver disease or a bile duct blockage such as gallstones and needs prompt testing.

Can stress or lack of sleep cause yellow eyes?

In people with Gilbert syndrome, stress, fasting, illness, dehydration and lack of sleep can cause mild, temporary yellowing of the eyes. It is harmless. In people without Gilbert syndrome, stress does not cause jaundice, so other causes should be checked.

Can yellow eyes go back to white?

Yes. Once the cause is treated, bilirubin levels fall and the whites of the eyes return to normal, usually over days to weeks. Yellowing from Gilbert syndrome fades within days. A yellow spot that is a pinguecula is permanent but harmless.