Bulbar conjunctivitis is also called episcleritis. It occurs when the thin outer layer of the eye covering the sclera, the white part, gets inflamed. (Learn More) This can cause swelling, pain, redness, and irritation in the white part of the eye. (Learn More)

There are no specific known causes for bulbar conjunctivitis, but some inflammatory conditions can increase the risk for this condition. (Learn More) Bulbar conjunctivitis can look like other conditions and requires a clinical diagnosis. (Learn More)

Typically, bulbar conjunctivitis goes away on its own without treatment. For severe cases, your doctor can prescribe medications to manage it. (Learn More)

Bulbar Conjunctivitis

The bulbar conjunctiva is the outer layer of the eye that helps protect and regulate the tear film. It covers the sclera, or the white part of the eye. The bulbar conjunctiva extends around your eye and up under your eyelids, but it does not cover your cornea.

Bulbar conjunctivitis, or episcleritis, is when this tissue, or the space between the sclera and conjunctiva, swells up, turns red, and becomes inflamed.

It is a fairly common cause of red eyes, affecting about 41 people per 100,000 population each year. Bulbar conjunctivitis is not considered to be a dangerous condition, and it does not cause significant visual complications. Episcleritis usually affects women more than men, and it is common in young adults.

Simple episcleritis leading to bulbar conjunctiva inflammation is the most common form. There are no specific raised areas with simple episcleritis; instead, the redness and inflammation are more spread out. Most of the time, the redness and swelling impact a specific area, or patches of areas, of the episcleral instead of the entire thing.

The other form of episcleritis, nodular episcleritis, is less common. It causes the formation of one or more elevated nodules that can also have a yellowish hue in addition to the redness.

Signs & Symptoms

Bulbar conjunctivitis differs from traditional conjunctivitis (pink eye) in that it occurs without an infection. Therefore, there is no pus or discharge from the eye. It is usually considered to be a mild, or benign, condition that can clear up on its own.

Redness, swelling, and discomfort generally peak within the first 12 hours of the onset of the condition and then start to fade within two or three days. Nodular episcleritis can last longer than simple episcleritis.

Bulbar conjunctivitis can flare up with acute attacks, dissipate, and then come back. Attacks may taper off and get less severe over the years before disappearing completely.

With a nodular episcleritis episode, you will often wake up with a nodule in the morning. The nodule can get bigger, more inflamed, and redder over a few days before resolving itself within a few days to weeks.

Symptoms of bulbar conjunctivitis include:

  • Redness in the whites of the eyes, either all over or just in one area in one or both eyes.
  • Mild pain or eye discomfort.
  • Irritation and the feeling of a foreign body in the eye.
  • Swelling of the eye.
  • Some sensitivity to light, in some cases.
  • Increased tearing or watery eyes.

There are typically no vision problems or issues reported with bulbar conjunctivitis. Most of the time, the redness and swelling are limited to one region of one eye, but the whole eye or both eyes can also be impacted by it. The condition can also come and go, which is called recurrent episcleritis.

Causes & Risk Factors for Bulbar Conjunctivitis

This condition can happen for seemingly no reason, and there is not a known cause for it. Unlike other forms of conjunctivitis, it is not typically caused by the introduction of a foreign object, trauma, infection, or allergens.

That being said, bulbar conjunctivitis is more common in people who also suffer from rheumatologic, systemic inflammatory, or autoimmune conditions like these:

  • Lupus
  • Rheumatoid arthritis
  • Rosacea
  • Crohn’s disease

 

Between 26 and 36 percent of people who get episcleritis also have a systemic disorder (a condition affecting the entire body) that can contribute to the development of this condition. Infections — such as those caused by the herpes virus, Lyme disease, cat scratch fever disease, and syphilis — can also be potential risk factors for developing bulbar conjunctivitis. People with eye diseases are also at higher odds for also contracting episcleritis.

Diagnosing Bulbar Conjunctivitis

The bulbar conjunctiva can be best seen by a trained professional ophthalmologist using a slit lamp. If the issues are under your eyelid, the doctor can gently hold back your eyelid while having you look up and down to assess the affected part of your eye. If the episcleritis is nodular, the bump or nodes will move separately from the underlying scleral tissue when manipulated.

Bulbar conjunctivitis is not infectious. However, it can often look like other forms of pink eye that are caused by bacteria, allergies, or viruses. The main differences are lack of vision problems, significant pain, extreme sensitivity to light, crusty buildup on eyelids and eyelashes, and discharge.

If you are experiencing additional symptoms aside from red and inflamed eyes, including major discomfort or visual problems, the issue may be deeper in the connective tissue, the sclera, and potentially not in the episcleral region. A trained ophthalmologist can make a diagnosis and formulate a treatment plan that is specific to you.

Treatment Methods

Usually, bulbar conjunctivitis is considered a mild condition that will clear up all by itself without medical intervention or invasive treatments. Often, you can ease the redness and irritation by using over-the-counter eye drops or artificial tears.

Keep artificial tears refrigerated for additional relief and to reduce swelling. You can then apply them up to four times per day. Symptoms of bulbar conjunctivitis usually resolve within a few days to three weeks.

If the pain or irritation is more intense and difficult to live with, talk to your doctor about prescribing corticosteroids. These medications are often topical in the form of eye drops. They are designed to be used on a short-term basis. Steroids can help to speed up the healing time of episcleritis, but they also have some risky side effects. As a result, they should be used with care for a limited time.

If pain is significant, or the episcleritis is chronic or keeps coming back, your doctor can prescribe either oral or topical anti-inflammatory medications. If you struggle with an underlying systemic condition or disease, treating the inflammation related to this issue can positively influence your episcleritis.

Talk to your eye doctor about any issues with your eyes or vision and any changes you notice. Discuss specific treatment options and methods of symptom management. In most cases, you will experience relief in a relatively short period of time.

References

Episcleritis. (February 2020). American Academy of Ophthalmology (AAO).

Episcleritis. (December 2019). Merck Manual.

An Atlas of Conjunctival and Scleral Anomalies. (November 2016). Review of Optometry.

Episcleritis. (2020). John’s Hopkins Medicine.

Bulbar Conjunctivitis. National Institutes of Health (NIH) National Cancer Institute.

Episcleritis. (August 2020). Stat Pearls.

Anatomy, Head and Neck, Eye Conjunctiva. (August 2020). Stat Pearls.