Citation Nr: 9830754 Decision Date: 10/15/98 Archive Date: 10/21/98 DOCKET NO. 97-29 193A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a cataract of the left eye. 2. Entitlement to service connection for a skin disorder, claimed as eczema. 3. Entitlement to a disability evaluation in excess of 10 percent for bilateral pars planitis and a cataract of the right eye. 4. Entitlement to an increased (compensable) disability evaluation for hemorrhoids. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD L. A. Samorajczyk, Associate Counsel INTRODUCTION The veteran served on active duty from January 1988 to May 1996. The April 1998 written argument of the veteran’s representative indicates that the veteran may wish to request to reopen claims for service connection for flat feet and a bladder infection with incontinence. These matters are referred to the regional office regional office (RO) for appropriate action. The issue of entitlement to a disability evaluation in excess of 10 percent for bilateral pars planitis and a cataract of the right eye is addressed in the Remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection is warranted for a cataract of the left eye and eczema. She states that her eczema is an unpredictable condition that recurs. In addition, she maintains that an increased evaluation is warranted for hemorrhoids. She notes that her December 1996 hemorrhoidectomy caused her to miss two weeks of work. The veteran’s representative requests that the appeal for an increased evaluation for hemorrhoids be remanded for a current examination. DECISION OF THE BOARD The Board of Veterans’ Appeals (Board), in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran’s claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports the claims for service connection for a posterior subcapsular cataract of the left eye and a skin disorder, characterized as hyperhidrosis and eczema. It is further the decision of the Board that the preponderance of the evidence is against the claim for an increased (compensable) evaluation for hemorrhoids. FINDINGS OF FACT 1. The RO has obtained all available relevant evidence necessary for an equitable disposition of the appeal. 2. A posterior subcapsular cataract of the left eye cannot be disassociated from the in-service findings of a left cataract and subcapsular changes. 3. A skin disorder, characterized as hyperhidrosis/eczema, cannot be disassociated from the in-service findings of dyshydrotic eczema. 4. In October 1997, Department of Veterans Affairs (VA) examination revealed no evidence of hemorrhoids, fissures, bleeding, or anemia. CONCLUSIONS OF LAW 1. A posterior subcapsular cataract of the left eye was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1998). 2. A skin disorder, characterized as hyperhidrosis and eczema, was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1998). 3. The criteria for an increased (compensable) evaluation for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.114, Diagnostic Code 7336 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran’s claims are well grounded within the meaning of 38 U.S.C.A. § 5107 in that she has presented claims that are plausible. The Board finds that the facts relevant to the issues on appeal have been properly developed and that the statutory obligation of VA to assist the veteran in the development of her claims has been satisfied. 38 U.S.C.A. § 5107(a). With respect to the representative’s April 1998 request that the appeal for an increased evaluation for hemorrhoids be remanded for an examination more current than the “last examination” in 1996, the Board notes that a VA examination of the rectum and anus was performed in October 1997. The veteran has not presented argument or evidence that challenges the findings of that examination. I. Service Connection Claims Basic entitlement to disability compensation may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A. Cataract of the Left Eye Service medical records reveal that hyperopic astigmatism was assessed in October 1988. In October 1989, a large vitreous floater was observed in the right eye. In February 1990, pars planitis was assessed. Steroids were injected into the conjunctiva of the right eye for the treatment of pars planitis. In March 1990, the veteran complained of a yellow mucous in both eyes. Bilateral visual acuity of 20/20 with glasses was observed. Bilateral conjunctivitis, probably bacterial, was assessed. In May 1990, compound hypermetropic astigmatism of both eyes was assessed. It was noted that there was no binocular dysfunction. In August 1990, steroids were injected into the conjunctiva of the right eye. In October 1990, examination revealed vitreous 2+ cells in the right eye and vitreous 1+ cells in the left eye. Pars planitis of the right eye and mild vitritis of the left eye were noted. In November 1990, examination revealed bilateral floaters. Later that month, it was noted that the left lens was clear. In February 1991, the veteran complained of photophobia. Examination revealed a fine posterior subcapsular cataract of the right eye. The lens of the left eye was clear. Steroids were injected into the conjunctiva of the right eye. In March 1991, it was noted that the left lens was clear. In May 1991, the veteran complained of increased debris in the visual field of the left eye. Examination revealed a clear left lens and vitreous 2-3+ cells. In September 1991, examination of the right eye revealed a posterior subcapsular cataract in the lens, 2+ vitreous cells, and snowballs in the peripheral retina. Examination of the left eye revealed fine stippling of the lens, 1+ vitreous cells, and a small amount of opacity in the periphery. A probable mild increase in uveitis of both eyes was assessed. In October 1991, both eyes were injected with a post subtenons steroid. In November 1991, decreased visual acuity, secondary to “SCL,” right greater than left, was assessed. In December 1991, it was suspected that the veteran’s hazy vision was secondary to an increasing cataract of the right eye. In March 1992, examination revealed that the left lens was clear. The assessments were of a right eye cataract, mildly active pars planitis of the right eye, and quiet pars planitis of the left eye. In August 1992, allergic conjunctivitis, a progressing right eye cataract, and stable pars planitis were assessed. Upon examination in January 1993, peripheral scarring of both eyes, right greater than left, was observed. In March 1995, the veteran complained of more floaters in the right eye and a few floaters in the left eye. Examination revealed a 1+ posterior subcapsular cataract in the right lens and a trace posterior subcapsular cataract in the left lens. Later that month, conjunctivitis of the left eye was assessed. In June 1995, a slit lamp examination revealed a 2+ posterior subcapsular cataract of the right lens and a 1+ posterior subcapsular cataract of the left lens. In April 1996, a Medical Evaluation Board reported that a lenticular examination had revealed a small posterior subcapsular cataract near the visual axis in the right eye and a minimal posterior subcapsular change in the left eye. Bilateral pars planitis, a small posterior subcapsular cataract of the right eye and a visually insignificant subcapsular change in the left eye were diagnosed. It was noted that the veteran would require frequent follow up treatment to insure against the reactivation of retinal inflammation and to follow any progression of the cataracts. It was further noted that the etiology of the cataracts might be secondary to either chronic inflammation due to pars planitis or systemic steroid use. Upon VA examination in July 1996, corrected distant visual acuity of 20/40 and 20/40+ was observed in the right and left eyes, respectively. The visual fields were normal to count fingers upon confrontational visual field examination. Examination of the right lens revealed a posterior subcapsular cataract of approximately gray +2. The lens of the left eye was clear. An epiretinal membrane was observed inferior to the right macula, while the left eye was normal. The peripheral examination revealed vitreous debris. The examiner diagnosed pars splenitis, right eye great than left eye. It was noted that pars splenitis was a chronic inflammatory disease of the eye that could cause blindness in the long term, either secondary to cataracts or secondary to chronic inflammation. The examiner also diagnosed a posterior subcapsular cataract in the right eye, most likely secondary to steroid treatment, and an epiretinal membrane in the right eye, most likely secondary to intraocular inflammation. VA clinical records reveal that the veteran complained of pars planitis in July 1997. A split lamp examination revealed a 1+ posterior subcapsular cataract in the right eye and a trace posterior subcapsular cataract in the left eye. Private clinical records reveal that the veteran complained of an increase in left eye floaters and a slight decrease in overall vision in August 1997. A slit lamp examination of the lenses revealed 2+ central posterior subcapsular cataracts in both eyes. A fundus examination revealed mild vitreous debris in both eyes. The diagnoses were of pars planitis in both eyes and posterior subcapsular cataracts, right greater than left. Upon VA examination in October 1997, a slit lamp examination revealed 2+ posterior subcapsular changes in the right eye and trace 1+ nuclear sclerosis in the left eye. Pars planitis of both eyes and a right posterior subcapsular cataract were diagnosed. The examiner reported that evidence of a left eye cataract had not been visible, although the veteran had reported that the cataract was very small. It was noted that a VA examiner had reported “this” in July 1996. The examiner noted that the funduscopic lamp in the examining room had not been bright enough to get a good look at the lens. A review of the record reveals that a number of left eye abnormalities were noted in service. Notably, in March 1995, examination revealed a trace posterior subcapsular cataract in the left lens. In June 1995, a slit lamp examination revealed a 1+ posterior subcapsular cataract of the left lens. Upon Medical Evaluation Board in April 1996, a minimal posterior subcapsular change was observed in the left eye. While a clear left lens was observed upon VA examination in July 1996, a July 1997 VA split lamp examination revealed a trace posterior subcapsular cataract in the left eye. Private clinical records indicate that an August 1997 slit lamp examination of the lenses revealed 2+ central posterior subcapsular cataracts in both eyes. Although a VA examiner did not find evidence of a cataract of the left eye in October 1997, the examiner noted that the funduscopic lamp in the examining room had not been bright enough to get a good look at the lens. With reasonable doubt resolved in the veteran’s favor, and in light of the continuity of the veteran’s left eye complaints, the Board concludes that the posterior subcapsular cataract of the left eye observed in July 1997 and August 1997 cannot be disassociated from the in-service findings of a left cataract and subcapsular changes. B. Skin Disorder Service medical records reveal that the skin was clinically evaluated as normal upon enlistment examination in December 1987. The veteran complained of an itchy face in March 1988. First-degree sunburn was assessed. In February 1989, the veteran complained of a two-week history of a non-pruritic rash on the left shin. Lesions and scales were observed. Eczematous lesions were assessed. In March 1989, serpiginous groups of vesicular-looking papules were observed on the veteran’s hands. Dyshydrotic eczema was assessed. In July 1989, the veteran complained of a rash on the feet. It was noted that she had dyshydrotic eczema on the hands and feet. In April 1990, small papules and comedones were observed on the face and shoulders. Mild acne was assessed. In June 1990, acneform lesions were observed on the face, variciform lesions were observed on the hands, and granuloma annulare was observed on the dorsa of the feet. In January 1993, an erythematous rash was observed on the left foot. In July 1993, the veteran complained of a rash on the upper thighs of both legs. Examination revealed a red, circular, pruritic flat rash. Tinea cruris was assessed. In October 1993, eczema was observed on the right hand. In July 1994, the veteran complained of a rash of the hands. It was noted that she had a history of dyshydrotic eczema. Examination revealed minimal peeling of the palms and fingertips. Dyshydrotic eczema was assessed. In March 1995, the veteran complained of eczema of the hands. She stated that she had completed a lot of cleaning with unprotected hands. Examination revealed a peeling patch of eczema in the central right palm. The hands otherwise looked dry, and some of the fingers were chapped. The impression was of hand eczema, suspect irritant. In April 1996, a Medical Evaluation Board noted that the veteran’s past medical history was significant for eczema. Later that month, the veteran reported that she had not sought medical care for a rash on her right foot. The health care provider assessing the veteran observed an interdigital rash on the right foot and diagnosed tinea pedis. In addition, it was noted that eczema was present on both hands. Upon VA examination in July 1996, the veteran complained of episodes of eczema on her hands. She stated that patches of eczema were characterized by redness and swelling. She stated that rashes cleared after one-and-one-half or two months. Examination revealed that the skin was essentially clear. There was some scaling on the feet, particularly the right foot, which resembled Athlete’s foot. The examiner diagnosed eczema, by history, not active on examination, and tinea pedis of both feet. In an October 1996 rating decision, the RO granted service connection for tinea pedis. Upon VA examination in October 1997, the veteran complained of a three or four-year history of intermittent hyperhidrosis-like symptoms. She stated that the symptoms occasionally occurred during the spring and summer. She reported that she observed small bullae on the palms of both hands and sometimes in the interdigital spaces. She complained of occasional pruritus. She reported that pus sometimes resulted from the lesions. She stated that triamcinolone had been helpful. The examiner reported that there was no evidence of eczema. Examination revealed no lesions. There was no ulceration, exfoliation, or crusting. The examiner diagnosed hyperhidrosis/eczema. The Board is cognizant that there was no evidence of active eczema upon VA examinations in July 1996 and October 1997. Regardless, the VA examiner diagnosed hyperhidrosis/eczema following VA examination in October 1997, based upon the veteran’s history of episodes of intermittent hyperhidrosis- like symptoms. The service medical records support the veteran’s complaints of recurring skin problems. Eczema or lesions were observed on the hands in March 1989, July 1989, June 1990, October 1993, July 1994, March 1995, and April 1996. In April 1996, a Medical Evaluation Board noted that the veteran’s past medical history was significant for eczema. With reasonable doubt resolved in the veteran’s favor, and in light of the continuity of the veteran’s episodic skin complaints, the Board concludes that hyperhidrosis/eczema cannot be disassociated from the in-service findings of dyshydrotic eczema. II. Increased Evaluation for Hemorrhoids Service medical records reveal that the veteran complained of increased pain and palpable nodules near the rectal opening in February 1989. Examination revealed a one-half centimeter hemorrhoid at the two o’clock position. There was no active bleeding, fissure, or discharge. Upon examination in January 1993, the anus and rectum were clinically evaluated as normal. Upon VA examination in July 1996, the veteran reported that hemorrhoids had developed in 1989. She complained of itching and burning. She stated that she experienced rare bleeding. She reported that she had used medication with fair results. Examination revealed hemorrhoids at the two and three o’clock positions. The examiner diagnosed external and internal hemorrhoids. VA clinical records reveal that the veteran complained of severe discomfort and pain secondary to thrombosed hemorrhoids in December 1996. Examination revealed external thrombosed hemorrhoids at the two, five, and ten o’clock positions. A hemorrhoidectomy was performed. In January 1997, the veteran complained of some pain and occasional bleeding. She stated that the pain was improving. Examination revealed that the perianal area was clear. There were no visible hemorrhoids or fissures. A small skin tag was present. It was noted that the veteran was doing well. Upon VA examination in October 1997, it was noted that three hemorrhoids had been surgically excised in December 1996. The veteran reported that she had had no problems with sphincter control, soilage or involuntary bowel movements. She stated that no pads were needed. She complained of some fecal urgency and occasional discomfort. She reported that she used Tucs pads at home. Examination revealed no colostomy or evidence of fecal leakage. There were no signs of anemia. The rectum and anus appeared normal, except for two small skin tags. There were no hemorrhoids or fissures. There was no evidence of bleeding. Under 38 C.F.R. § 4.114, Diagnostic Code 7336, a noncompensable evaluation is warranted for mild or moderate hemorrhoids. A 10 percent evaluation is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The record reveals that hemorrhoids were surgically excised in December 1996. In October 1997, VA examination revealed no evidence of hemorrhoids, fissures, bleeding, or anemia. Therefore, an increased (compensable) evaluation is not warranted. See 38 C.F.R. § 4.114, Diagnostic Code 7336. A review of the record reveals that the RO considered the assignment of an extraschedular evaluation, and provided the veteran notice of the consideration. Thus, in reaching this decision, the Board has also considered a higher rating on an extraschedular basis, but finds that an increase on such a basis is not warranted. To accord justice to the exceptional case where the schedular evaluation is found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be granted. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Although the veteran reports that that her December 1996 hemorrhoidectomy caused her to miss two weeks of work, there is no evidence of any other periods of hospitalization or interference with employment. Consequently, in the absence of an exceptional or unusual disability picture, the Board concludes that the assignment of an extraschedular evaluation pursuant to 38 C.F.R. § 3.321 (b)(1) is not appropriate. ORDER Service connection for a posterior subcapsular cataract of the left eye is granted. Service connection for a skin disorder, characterized as hyperhidrosis and eczema, is granted. An increased (compensable) evaluation for hemorrhoids is denied. REMAND As noted previously, the Board has determined that service connection is warranted for a posterior subcapsular cataract of the left eye. In April 1998 written argument, the veteran’s representative requested that the appeal for an increased evaluation for the veteran’s eye condition be remanded for an examination more current than the “last examination” in 1996. A review of the record reveals that the veteran was last afforded a VA eye examination in October 1997. At that time, corrected distant visual acuity of 20/40 and 20/25 in the right and left eyes, respectively, was observed. Other private and VA clinical records dated in 1997 reflect findings of right eye corrected distant visual acuity of 20/50, 20/60, and 20/70. Overall, the Board is of the opinion that additional development of the record is needed in order to determine the underlying medical issues to enable the Board to render a final determination. Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the case is REMANDED to the RO for the following development: 1. The RO should contact the veteran and ask that she provide the names and addresses of all health care providers who have afforded her treatment for eye disorders since October 1997. After obtaining the necessary permission from the veteran, the RO should obtain copies of all treatment records and associate them with the claims folder. 2. After copies of all available treatment records have been associated with the claims file to the extent possible, the veteran should be afforded a VA eye examination to determine the nature and extent of her bilateral pars planitis and cataracts. The claims folder and a separate copy of this remand must be made available to and reviewed by the examiner prior to conduction and completion of the examination. The examiner should record pertinent medical complaints, symptoms, and clinical findings. All necessary tests and studies should be performed, including visual acuity testing and Goldmann visual field testing. The examiner should provide numeric interpretations of all visual field test graphs. In addition to impairment of visual acuity and visual field loss, complaints of pain, rest requirements, or episodic incapacity should be carefully noted. Any other functional impairment caused by the bilateral pars planitis and cataracts should be described in detail. The examiner should specify whether active pathology is present. Finally, the examiner should describe the effect of the veteran’s bilateral pars planitis and cataracts on her ability to perform average employment in a civil occupation. 3. The RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination report and opinions to ensure that they are responsive to and in complete compliance with the directives of this remand. If they are not, the RO should implement corrective procedures. 4. After the development requested above is completed to the extent possible, the RO should again review the claims for an evaluation in excess of 10 percent for bilateral pars planitis and a cataract of the right eye, with consideration of the effect of the grant of service connection for a posterior subcapsular cataract of the left eye. If the benefit sought on appeal remains denied, the veteran and her representative should be given a supplemental statement of the case with regard to the additional development and should also be afforded an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action until otherwise notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. John E. Ormond, Jr. Member, Board of Veterans’ Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1998). - 2 -