An unusual case of unilateral scleral icterus.

Sir,

A 54-year-old man presented with a left-sided middle cerebral artery (MCA) territory infarct [Figure 1] and underwent decompressive craniectomy. He had an uneventful postoperative recovery but remained hemiplegic on the right side. Six weeks later he was admitted with complaints of vomiting. His operative site flap was lax and CT scan of brain showed no raised intracranial pressure [Figure 2]. He was found to have icterus in the left eye alone [Figures 3 and 4]. Liver function tests showed elevated serum bilirubin levels [1.9 mg%] and mildly deranged liver enzymes [SGOT 98 IU/L, SGPT 86IU/L]. Ultrasound scan of the abdomen was normal. Viral markers for hepatitis B and C were negative. The jaundice subsided on conservative treatment.

Figure 1

Preoperative CT scan showing left MCA territory infarct with midline shift of 10.5 mm to the right with mass effect on the ventricles

Figure 2

Postoperative CT scan showing resolution of the midline shift

Figure 3

Unilateral [left sided] yellowish discoloration of sclera. The bulge of the decompressive craniotomy is visible on the left side

Figure 4

Unilateral [left sided] yellowish discoloration of sclera. The ocular movement clearly shows it is not a “glass eye”

Unilateral scleral icterus is a very rare finding. We came across an image of a patient with a glass eye and icterus in the normal eye who had undergone surgery for ocular melanoma and subsequently developed liver metastasis with jaundice.[1] But this should be called jaundice in a monocular patient and not unilateral icterus. It has also been described with associated edema following porta caval anastamosis[2] but in these cases the edema and jaundice both occur on the same side due to binding of bilirubin to the albumin of ascitic fluid that dissects into subcutaneous spaces. Meakins[3] described a “definite localization of pigmentation” in patients with circulatory failure. In his series of six cases all patients had yellow discoloration on the upper torso, face and upper limbs only. He proposed that in circulatory failure the composition of tissue fluid is unaffected by changes in plasma leading to differential pigmentation.

Edema on the hemiplegic side and jaundice on the other side was described in two cases by Page.[4] Korpelainen et al.,[5] proposed that there is increased vasomotor tone on the hemiplegic side due to loss of cortical and subcortical inhibition on vasomotor neurons in patients with ischemic stroke. This leads to reduced blood flow on the side opposite to the infarction and might explain this phenomenon.

Our patient had neither edema nor any evidence of cardiac failure or cirrhosis. However, on pointed questioning he indicated that he was having a sensation of coldness in the hemiplegic side and hence we feel that globally decreased blood flow in the right side may have been responsible for sparing of the right sclera. However, we have never encountered unilateral scleral icterus prior to this case. It is possible that in the presence of a more elevated bilirubin level or delayed presentation to the hospital this uncommon finding would have been missed.