Paradoxical appearance of new or expansion of existing optochiasmatic tuberculoma, leading to severe vision loss, is a devastating complication in patient with tuberculous meningitis.

We report a series of 8 cases of tuberculous meningitis that developed paradoxical vision loss associated with optochiasmatic tuberculoma. Clinical assessment and magnetic resonance imaging (MRI) done at presentation, at the time of deterioration, and at 9 months were analyzed.

All patients had good vision acuity and normal visual field at baseline. None of them had optochiasmatic tuberculoma on magnetic resonance imaging at baseline, though 3 patients had optochiasmatic arachnoiditis. The mean interval of onset of paradoxical optochiasmatic tuberculoma was 41 days after starting antituberculosis therapy. Paradoxical optochiasmatic tuberculoma was associated with vision deterioration in all patients, 6 of whom developed severe vision loss (vision acuity ≤6/60). Repeat neuroimaging showed new optochiasmatic tuberculoma in all patients. All patients were treated with extended course of dexamethasone for 6 weeks along with antituberculosis therapy. Two patients died at 62 and 211 days respectively. Repeat neuroimaging in rest of the patients showed resolution of optochiasmatic tuberculoma. At 9 months follow-up, vision improved completely in 3 patients and partially in 3 patients.

Prompt recognition of paradoxical optochiasmatic tuberculoma with the help of vision assessment and neuroimaging is vital for patient's life and vision. Paradoxical reactions should not be labeled as a new or resistant infection. The prior treatment schedule should continue, and dexamethasone may be added or its dose enhanced.