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'Conjunctival Icterus,' Not 'Scleral Icterus'

Ramesh C. Tripathi, MD, PhD; Linas A. Sidrys, MD
JAMA. 1979;242(23):2558. doi:10.1001/jama.1979.03300230014016.
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To the Editor.—  The expression "scleral icterus" generally used by physicians is grossly incorrect. For decades, physical diagnosis primers have cued medical students to look for "scleral icterus" in the patient with jaundice; the standard medical textbooks perpetuate this term. Specifically, several texts authoritatively state that jaundice can be detected in the sclera at a plasma bilirubin concentration of approximately 2 mg/dL.We have studied histological sections of globes from patients with clinical jaundice, including cases of biliary obstruction and Wilson's disease. We found that of all ocular tissues, the least amount of bilirubin staining is seen in the scleral stroma. In the case of Wilson's disease we studied, the plasma bilirubin concentration reached 60 mg/dL and the degree of clinical jaundice was most remarkable, yet almost no bilirubin pigment was present in the sclera. It is the conjunctiva, a mucous membrane rich in stromal vessels, that turns yellow, not


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