When the whites of your eyes (sclera) turn yellow while the eye surface appears red or bloodshot, it signals two distinct and potentially serious health issues. Scleral yellowness, medically termed jaundice, is a systemic sign indicating a problem with the body’s processing of bilirubin. Ocular redness, or hyperemia, is a localized symptom of inflammation or irritation on the eye’s surface. While many common conditions cause red eyes, the combination of red and yellow coloration indicates an underlying systemic disease affecting both liver function and ocular tissues, necessitating a thorough medical investigation.
Causes of Scleral Yellowness
Scleral yellowness, or jaundice, results from the accumulation of bilirubin, a yellow pigment created when the body breaks down old red blood cells. Normally, this bilirubin travels to the liver for processing and is then excreted from the body in bile. Jaundice occurs when any part of this metabolic pathway is disrupted, leading to elevated bilirubin levels in the bloodstream, a condition called hyperbilirubinemia.
One category is pre-hepatic jaundice, which occurs before the bilirubin reaches the liver cells, typically due to excessive red blood cell destruction, or hemolysis. The liver is overwhelmed by the rapid production of bilirubin and cannot process it quickly enough, leading to a buildup of the unconjugated form of the pigment. Conditions like severe hemolytic anemia fall into this category, where the lifespan of red blood cells is drastically shortened.
The most common cause of yellow eyes is hepatic jaundice, which involves direct damage or dysfunction of the liver cells themselves, known as hepatocytes. Diseases like viral hepatitis, alcohol-related liver disease, or cirrhosis impair the liver’s ability to take in, process, or conjugate the bilirubin. This causes both processed (conjugated) and unprocessed (unconjugated) bilirubin to leak into the blood, resulting in the characteristic yellow staining of the sclera.
A third mechanism is post-hepatic jaundice, or obstructive jaundice, where the issue lies in the plumbing system after the liver has done its job. This occurs when the bile ducts, which transport conjugated bilirubin to the small intestine for excretion, become blocked. Common causes of this obstruction include gallstones, tumors in the pancreas head, or strictures that physically prevent the bile from flowing, forcing the processed bilirubin back into the general circulation.
Causes of Ocular Redness
Ocular redness, or a bloodshot appearance, is caused by the dilation or bursting of the tiny blood vessels in the conjunctiva, the thin, clear membrane covering the sclera and lining the inside of the eyelids. This vascular response, known as hyperemia, is the eye’s way of reacting to irritation, infection, or injury.
The redness is often generalized across the eye surface in conditions such as allergic conjunctivitis, where an immune response causes widespread vessel dilation and inflammation. Similarly, severe dry eye syndrome or prolonged eye strain can trigger this generalized redness as the surface tissues become irritated and dehydrated. These common causes of redness are usually localized problems without systemic implications.
A more localized type of redness is a subconjunctival hemorrhage, which appears as a bright red patch on the white of the eye. This happens when a small blood vessel beneath the conjunctiva breaks, often due to a sudden increase in pressure from coughing, sneezing, or vomiting. While alarming in appearance, the blood is contained and usually reabsorbs on its own, functioning much like a bruise on the eye surface.
Conditions Where Yellow and Red Occur Together
The simultaneous presence of yellow and red eyes strongly suggests a serious underlying systemic condition that affects both the liver and the vascular or inflammatory system of the eyes. These conditions link the systemic failure responsible for jaundice with an ocular manifestation of inflammation or clotting disorder.
Acute, severe viral hepatitis or drug-induced liver toxicity can cause a sudden onset of jaundice due to widespread hepatocyte damage. In this setting, the systemic inflammation or associated coagulation defects can also manifest in the eyes. Platelet and clotting factor production is impaired by the failing liver, which can lead to spontaneous subconjunctival hemorrhages, presenting as patches of red on the already yellowed sclera.
Severe leptospirosis is a classic example of this dual presentation. The bacterial infection causes acute liver and kidney failure, resulting in deep jaundice. The infection often causes a specific type of ocular redness called conjunctival suffusion, characterized by redness and swelling of the conjunctiva without the pus or discharge typical of common conjunctivitis.
Severe hemolytic anemia crises, where red blood cells are destroyed rapidly, cause jaundice by overwhelming the liver’s capacity to process bilirubin. In severe cases, the accompanying systemic illness can trigger inflammation of the blood vessels or lead to a condition known as anemic retinopathy. This retinopathy can cause hemorrhages in the retina and occasionally in the conjunctiva, presenting as a red appearance alongside the yellowing.
When Immediate Medical Attention is Necessary
Any new onset of scleral yellowness warrants prompt medical evaluation, even if no other symptoms are present. The combination of yellow and red eyes, especially with other systemic symptoms, may indicate an acute, life-threatening emergency. Immediate medical attention is necessary if the yellowing or redness is accompanied by any of the following serious symptoms:
- Change in mental status, such as confusion, disorientation, or excessive sleepiness, which can signal liver encephalopathy.
- Severe, sudden pain in the upper right side of the abdomen or the back, indicating an acute obstruction of the bile ducts or severe liver inflammation.
- High fever or uncontrollable chills, suggesting a severe systemic infection or inflammation.
- Dark, tarry stools or vomiting blood, which indicates internal bleeding.
- Sudden vision changes, severe eye pain, or the feeling of pressure within the eye.