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Letters |20 February 2001

Conjunctival Icterus

John J. Kuiper, MD

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • University of California, Los Angeles, School of Medicine; Los Angeles, CA 90095-1736 (Kuiper)
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TO THE EDITOR:
Medical students learn that scleral icterus is an important and often early sign of hyperbilirubinemia. Yet, in each of the eight editions (1892 to 1916) of the classic textbook of medicine that he authored, William Osler defined icterus as yellow “tinting of the skin and conjunctivae.” The first six editions (1927 to 1943) of Cecil's Textbook of Medicinelocalize the initial appearance of yellow pigmentation in jaundice to the conjunctiva. In the mid-1940s, sclera displaced the conjunctiva as the site of localization of ocular icterus in textbooks (1, 2)—on the basis of studies published a decade earlier in Germany showing the strong affinity of bilirubin for elastin (3, 4). The higher the elastin content of a tissue, the greater its bilirubin content and the more intense the icteric discoloration. In reality, it is the innermost layer of conjunctiva (the subepithelial lamina propria) and its contiguous, most superficial aspect of the sclera (the episclera) that are endowed with elastic fibers. The sclera proper contains far less elastic tissue.
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Kuiper JJ. Conjunctival Icterus. Ann Intern Med. 2001;134:345–346. doi: 10.7326/0003-4819-134-4-200102200-00029

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Published: Ann Intern Med. 2001;134(4):345-346.

DOI: 10.7326/0003-4819-134-4-200102200-00029

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2001 American College of Physicians
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704

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