Discussion:
According to our knowledge this might be first cases in Bangladesh presented with this rare condition of post-COVID-19 retinal hemorrhage. Though a straightforward clear correlation could not be established regarding study configuration, as male patient may develop ocular consequences that may have influenced retinal changes as a result of post-Covid consequences or 43 days after receiving a Live-virus vectored based COVID-19 vaccine (AstraZeneca vaccine). Theoretical pathophysiology of COVID-19 inactivation-related ocular inflammation is unknown. Respectively molecular mimicry and antigen-specific cellular and antibody-mediated immune system disorders have been suggested as possibilities (17-19). The discovery of COVID-19 viral RNA in the retina is significant. In addition, a new host cell entrance route involving the receptor CD147 has been identified (20), CD147 is present at moderate-to-high levels throughout all cell types of the human retina, particularly in retinal ganglion cells (GCs), in contrast to ACE2 (21). Furthermore, positive RT-PCR findings have been published in human retinal biopsies, implying that the viral proteins is invading retinal nerves specifically (4). Certain coronavirus variants can invade retinal cells in other vertebrate species both in situ and in retinal cultured cells (22) and in vivo following viral proteins were injected intravitreally(23) producing experimental coronavirus retinopathy(ECOR)(24, 25). Three out of 14, RB samples were positive for SARS-CoV-2 RdRp-gene, E-gene, and Orf nCoV-gene-specific sequences in the retina in one research in Germany (4). Most notably, retinal microangiopathy exhibited as cotton wool patches (diagnostic and therapeutic sign related with nerve fiber ischaemia) was seen in 6 out of 27 outpatients evaluated by retinal fundoscopic, B-scan OCT(Optical Coherence Tomography), and Optical Coherence Tomography Angiography angiography (OCT-A) at a mean of 43 days following COVID-19 disease onset in Spain (26). Retinal hemorrhages were identified in 9% of COVID-19 victims even during acute phase of infection, cotton wool patches in 7%, dilated veins in 28%, and twisted vessels in 13% in a study in Italy (27). With no complaints or indicators of intraocular inflammation, four patients out of 12 patients showed with mild cotton wool patches and microhemorrhages across the retinal apartment(7). In terms of our own experience, we had a similar case of retinal hemorrhage. There is no intraocular inflammation or discomfort in the eyes. In COVID-19 individuals, there are at minimum two basic ways that vascular injury can occur: The first is a prothrombotic state, similar to disseminated intravascular coagulation (DIC)(28) and secondly, due to spontaneous viral infection of the vascular endothelium and widespread endothelial dysfunction, a vasculitis-like reaction starts(29). Retinal hemorrhages that represent the outcomes in retinopathy related to blood dyscrasias may be a connection with SARSCoV-2 in the perspective of a coagulopathy evoked by the pathogen in the utter lack of arterial hypertension, no symbols of diabetic retinopathy, and the total lack of other cardiovascular risk, as well as the improvement after the COVID-19 regimen, as well as the betterment after the COVID-19 medical therapy. Retinal hemorrhages (subretinal, subhyaloid, or intraretinal), capillary tortuosity, and cotton balls patches are all ophthalmic symptoms of blood dyscrasia. Hype viscosity and prolonged arteriovenous passage time are assumed to be the reasons(30). Our case was a subhyaloid subtype of retinal hemorrhage. In, Abu Dhabi(12), Scleritis and episcleritis were detected in 4 of 9 instances, on average 5 days after the first dose of the vaccination. After compiling all of the data from our report and the other assessment research, we discovered that several clinical findings are in accordance across all of these patients, such as the nature of the retinal hemorrhage or abnormalities pertaining to the covid19 complication and vaccination, but our case was unique in that it was post covid retinal hemorrhage or late COVID-19 vaccine induced retinal hemorrhage. The baseline retina record from validated COVID-19 patients who had been immunized for COVID-19 and were later admitted for ocular treatment of extreme and urgent condition was a major strength of our study. Patients with subhyaloid hemorrhage were more likely to show with systemic hypercoagulopathy and cytokine storm during retina evaluation. There are certain limitations to our research. First, our case only included young, healthy men, limiting the generalizability of our findings. Second, complications occur at different/long times and we don’t obtain a definitive answer, whether it’s for post COVID-19 or vaccine-related issues. Third, no supplemental hematological and biochemical analyses/studies, such as D-dimer and prothrombin time, bleeding time, clotting time would be suitable to alternative way of COVID-19 hyper-coagulopathy as a biological process for the retinal signboards, as well as laboratory levels of serum, such as C reactive protein, to link the retinal outcomes to correlating systemic inflammation. Also, while there was no massive distinction between patients with and without increased blood pressure, it could still be a significant contributor.