The relation of conjunctival pallor to the presence of anemia

J Gen Intern Med. 1997 Feb;12(2):102-6. doi: 10.1046/j.1525-1497.1997.00014.x.


Objective: To determine the value of conjunctival pallor in ruling in or ruling out the presence of severe anemia (hemoglobin < or = 90 g/L) and to determine the interobserver agreement in assessing this sign.

Design: Patients were prospectively assessed for pallor by at least one of three observers. All observations were made without information of the patient's hemoglobin value or of another observer's assessment.

Setting: Tertiary-care, university-affiliated teaching hospital.

Patients: Three hundred and two medical and surgical inpatients.

Measurements and main results: Likelihood ratios (LRs) calculated for conjunctival pallor present, borderline, and absent were as follows: pallor present, LR 4.49 (95% confidence interval [CI] 1.80, 10.99); pallor borderline, LR 1.80 (95% CI 1.18, 2.62); pallor absent, LR 0.61 (95% CI 0.44, 0.80). Kappa scores of interobserver agreement between paired observers were 0.75 and 0.54.

Conclusions: The presence of conjunctival pallor, without other information suggesting anemia, is reason enough to perform a hemoglobin determination. The absence of conjunctival pallor is not likely to be of use in ruling out severe anemia. With well-defined criteria, interobserver agreement is good to very good.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Anemia / diagnosis*
  • Bayes Theorem
  • Color
  • Confidence Intervals
  • Conjunctiva / pathology*
  • Female
  • Hemoglobins / analysis
  • Humans
  • Likelihood Functions
  • Male
  • Middle Aged
  • Observer Variation
  • Pallor*
  • Physical Examination / methods
  • Prospective Studies
  • ROC Curve


  • Hemoglobins