Seeing the Unseen: A Rare Ocular Complication of Tuberculous Meningoencephalitis

Tuberculous meningitis (TBM) is the most severe form of central nervous system (CNS) tuberculosis and carries significant morbidity, particularly when diagnosis is delayed. Cranial nerve involvement is a recognized complication, most frequently affecting the abducens nerve (CN VI); bilateral oculomotor nerve (CN III) palsy, however, is exceedingly rare and typically signifies pathology at the level of the midbrain. The oculomotor nerve originates from paired nuclei in the midbrain tegmentum at the level of the superior colliculus; any compressive or inflammatory lesion at this site can produce bilateral CN III deficits. We report a 70-year-old man with type 2 diabetes mellitus presenting with subacute fever, headache, and altered sensorium, who subsequently developed bilateral ptosis with ophthalmoplegia. The brain MRI demonstrated multiple disseminated tuberculomas with a focal midbrain lesion at the oculomotor nuclear-fascicular complex and communicating hydrocephalus. This case highlights an uncommon neuro-ophthalmological manifestation of TBM and emphasizes the critical role of early clinico-radiological correlation in diagnosis and management.