Examining the Eyes of an Older Person

Scleral Discolorations

White or gray triangular or oval spots on the temporal side of the eye (Bitot's spots) suggest severe vitamin A deficiency. Scleral atrophy appears as a blue patch and suggests:

• Scleromalacia;
• Corticosteroid therapy;
• Connective tissue disease like osteogenic imperfecta (Eddowes' sign);^[10] or
• Iron deficiency anemia.

Muddy sclera (a normal variant) has a brownish color that is not to be confused with scleral icterus. To confirm the scleras are indeed muddy, have the patient look up and examine the inferior portion of the sclera. The portion that is not normally exposed will be whiter. If icterus is present, the whole sclera is yellow. Senile hyaline plaques are noted at the insertions of the medial and lateral rectus muscles. They tend to be square or rectangular in shape.

The bright yellow discoloration of scleral icterus is an important sign of an elevated bilirubin. If at all possible, use natural direct sunlight to illuminate the eye.

A large painless bright red hemorrhage may appear spontaneously during sleep or after coughing or sneezing. For many elderly people, the cause is unknown but may be due to capillary fragility. Local trauma can produce bleeding but if the head trauma occurred 1 or 2 days earlier, you must consider basilar skull fracture. Systemic causes include:

• Vasculitis (always with other signs);
• Thrombocytopenia;
• Clotting disorders;
• Diabetes mellitus; and
• Hypertension.

If the bleeding does not clear over several days, consider Kaposi's sarcoma.