Clinical Medicine By the Light of Evidence

Sunday, July 8, 2012

Color of the Eyes
Motivation: Part of the checklist on the physical exam is looking at patients' eyes and deciding
on paleness. I would love to be able to gauge degree of anemia without Q6 blood draws, but are
the eyes a good way to decide on degree of anemia?
For background, while looking at the conjunctiva, pallor is determined by comparing the
posterior edge of the palpebra (just where it intersects with the conjunctiva) with the anterior
edge of the palpebra bordering the eyelashes. Normally, the anterior edge is redder than the
posterior edge. In anemia, the anterior and posterior edge are the same color. Pasted below are
pictures of a normal and anemia conjunctival exam:

Normal Conjunctiva

Conjunctival Pallor
Paper: Sheth, T.N., Choudhry, N.K., Bowes, M. et. al. "The Relation of Conjunctival Pallor to
the Presence of Anemia." J. Gen. Intern. Med. (1997); 12: 102-106.

Methods: 302 medical and surgical inpatients at The Toronto Hospital were prospectively
assessed for conjunctival pallor (present/borderline/absent) and compared to the patient's
hemoglobin. The observers (medical students and general internists) were initially trained on 25
patients but were blinded to the hemoglobin levels. While no primary endpoint was stated, the
overall goal was the utility of conjunctival pallor in ruling in or ruling out moderate anemia
(hemoglogin < 9 g/dL).
Results:
Cohort: Of the 302 patients examined, 171 were male and 131 were female. 55 had hemoglobin
less than 9 g/dL while 247 had higher values.
Conjunctival Pallor: With hemoglobin cutoff of 9 g/dL, the performance of pallor is as below:
- Sensitivity (pallor present): 14.5%
- Sensitivity (pallor present/borderline): 54.5%
- Specificity (pallor absent): 74.4%.
Discussion: In the final analysis, conjunctival pallor is just not a reliable test for anemia even for
trained observers. A definitely positive test only has sensitivity of about 15%. Even stretching
the boundary to positive or borderline positive only yields a sensitivity of about 54%. So,
anemia cannot be ruled out by conjunctival pallor. On the other hand, specificity is somewhat
higher though 25% of patients with hemoglobin > 9 g/dL remarkably also had conjunctival
pallor. Thus, if pallor is observed, the patient likely has anemia though even that is not a sure
thing (in the study, positive likelihood ratio of 4.49)! I guess CBC are here to stay.