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.