key: cord-0716168-yjv8kclx authors: Panigrahi, Pradeep K title: Comment on: Intracranial hypertension and visual loss following COVID-19: A case report date: 2021-08-03 journal: Indian J Ophthalmol DOI: 10.4103/ijo.ijo_1488_21 sha: 827eab429633dac3fc22a86cecb7e247b12420ff doc_id: 716168 cord_uid: yjv8kclx nan Dear Editor, With great interest, I went through the article Intracranial hypertension and visual loss following COVID-19: a case report by Ilhan B et al. [1] The authors have very nicely described a possible association of intracranial hypertension in a COVID-19 positive, obese patient. Benign intracranial hypertension can be associated with risk factors like obesity, intracranial venous thrombosis, medications, endocrine and metabolic factors. There are reports associating intracranial hypertension and Vitamin-B12 deficiency in literature. [2] [3] [4] The exact cause of association is yet to be ascertained, but the plausible mechanism is venous stasis due to hypercoagulability and hyperviscosity secondary to hyperhomocysteinemia. [5] In the present case, the patient had recently recovered from COVID-19 and was obese. Laboratory studies found Vitamin B-12 deficiency. Association between COVID-19 and intracranial hypertension seems more coincidental in this case rather than being causal. There was prompt resolution of disc edema following changes in diet and introduction of Vitamin B-12 therapy. The authors have mentioned obesity to be a primary factor responsible for clinical condition. However, clinical reduction in disc edema was not associated with significant reduction in weight. Correction of vitamin B-12 levels might have resulted in resolution of disc edema. A serum homocysteine level at baseline could have helped. It is very difficult to pin point on a single etiological factor when multiple risk factors are present. Being aware of possible associations can help in managing such conditions successfully. Nil. Dear Editor, We thank author(s) of the letter to the editor on our article "Intracranial hypertension and visual loss following COVID-19: a case report." [1, 2] The letter points out possible association between vitamin B12 deficiency and intracranial hypertension (IHT), which is a good discussion. Vitamin B12 deficiency has been reported in patients with IHT in various case reports. Possible relation and mechanism are not ascertained yet. Vitamin B12 deficiency has been related to many clinical manifestations including the central nervous system; however, IHT is not a prominent one among them. [3] A possible mechanism has been discussed as venous stasis due to hypercoagulability, and some cases had cerebral venous sinus thrombosis related to that, [4] which was not present in our case. A possible association of IHT with various hypercoagulation disorders has been studied, but vitamin B12 deficiency was not among them. [5] We started acetazolamide treatment together with vitamin B12 and recommended to lose weight. Resolution of papilledema and improvement in visual field could be related to acetazolamide, which is considered as mainstay therapy. The prominent risk factors for IHT in our patient were obesity, gender, and age. It is not possible to declare a cause and effect relationship with one case, but the important discussion is that COVID-19 could be a precipitating factor for IHT in this high-risk group, and when we search the literature, our patient is the first case discussed on this ground. Even if we discuss vitamin B12 deficiency as another risk factor in this patient, we should keep in mind this possible role of COVID-19 with the mechanisms discussed in our article. So, we think it is not possible to say "association between COVID-19 and IHT seems more coincidental in this case." It is necessary to study further on this topic to be aware of the condition and prevent severe morbidity. Nil. There are no conflicts of interest. Code mucor: Guidelines for the diagnosis, staging and management of rhino-orbito-cerebral mucormycosis in the setting of COVID-19 Invasive zygomycosis in India: Experience in a tertiary care hospital Intracranial hypertension and visual loss following COVID-19: A case report Intracranial hypertension in a dieting patient A patient with megaloblastic anaemia and idiopathic intracranial hypertension. Case history Intracranial hypertension and visual loss following COVID-19: A case report Comment on: Intracranial hypertension and visual loss following COVID-19: A case report Vitamin B12 deficiency: Recognition and management A pediatric patient with recurrent pseudotumor cerebri and vitamin B12 deficiency Benign intracranial hypertension associated to blood coagulation derangements