I'd say more likely real. It's the creature reflected, not terrain in the background. Looks like a shot taken in very shallow water, allowing reflected details in the sky to be seen -- but just clouds and blue sky. The other stuff, including the "moon" thing is just schmutz on the watch crystal.
A slightly different concept here (and not watch-related at all) -- a split shot I took in the Galapagos Islands: an underwater shot of a swimming marine iguana, while in the background a different iguana can be seen sunning itself on the rock on the surface, under a lovely blue and cloud-speckled sky.