Citation Nr: 0309132 Decision Date: 05/15/03 Archive Date: 05/27/03 DOCKET NO. 01-04 575A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for cataracts as secondary to the administration of steroids for treatment of service- connected Crohn's disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Johnson, Counsel INTRODUCTION The veteran served on active duty from September 1966 to August 1968. This matter initially came to the Board of Veterans' Appeals (Board) from a January 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The RO denied entitlement to service connection for visual/eye impairment as secondary to service- connected Crohn's disease. The veteran requested a hearing at the Board before a Veterans Law Judge (VLJ). A hearing was scheduled for the veteran before a VLJ in April 2003. Since he did not report for the scheduled hearing, his request for same is considered withdrawn. In February 2003, the veteran submitted additional evidence to the Board with the proper waiver of Agency of Original Jurisdiction consideration. See 38 C.F.R. § 20.1304 (2002). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has, to the extent possible, been accomplished. 2. The probative and competent medical evidence of record establishes that cataracts of both eyes are causally related to steroids used to treat the veteran's service-connected Crohn's disease. CONCLUSION OF LAW Cataracts of both eyes are proximately due to, or the result of the administration of steroids for treatment of service- connected Crohn's disease. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background A VA examination was conducted in connection with a pension claim in 1987. The examination of the eyes was within normal limits. VA records dated in 1994 reflect the complaints of and treatment for Crohn's disease. The records show that the veteran underwent a subtotal colectomy and ileostomy. In a May 1994 letter, DT (initials), OD, reported that he had performed a routine visual assessment the day before. The veteran complained of a decrease in his vision since his admission for treatment of ulcerative colitis. He reported taking a number of medications for the gastrointestinal condition and hypertension, which included corticosteroids. His last vision examination was one year prior and he denied unusual problems, or any previous eye injury or disease. Dr. DT opined that the veteran's macular problem looked worse than the visual findings suggested. Dr. DT indicated that he would have expected a large central scotoma, and that further questioning revealed a family history of problems with the back of the eye. Regarding the use of steroids, Dr. DT offered the following opinion: Of perhaps greater significance is the posterior subcapsular cataracts he is developing. My impression is that at his relatively young age these are probably associated with the use of steroids. VA treatment records dated in 1994 reflect the veteran's complaints of decreased visual acuity and examination findings. Significant vision loss was noted on a VA general medical examination of November 1994. The RO granted entitlement to service connection for Crohn's disease pursuant to the provisions of 38 U.S.C. § 1151 in July 1995. In July 1998, the Board remanded the issue of entitlement to special monthly compensation. In the remand, the Board determined that the claim for an eye disorder was an implied claim and requested the appropriate development, including obtaining an examination. An examination was performed in February 1999, and the examiner diagnosed Laber's disease of unknown etiology. The examiner indicated that for an etiology, one should contact the hospital where the veteran was initially seen in 1944. On the aid and attendance examination of February 1999, the examiner stated that the veteran was legally blind. In an October 2000 remand, the Board found that the February 1999 examination did not reflect compliance with the Board's July 1998 remand instructions. Another examination was requested. The examiner acknowledged a review of the claims folder in the December 2000 examination report, and diagnosed retinal atrophy of both eyes. A fluorescein angiogram was performed in January 2001. The examiner ruled out atrophy of the retinal pigment epithelium associated with steroid treatment for Crohn's disease, as well as Stargardt's hereditary macular degeneration-like atrophy of the retinal pigment epithelium versus a cone dystrophy bilaterally. The examiner made the following comment: I have never seen a case of Crohn's disease. Thank you for sharing this angiogram with me. I would appreciate a follow-up when the final diagnosis is established. VA records show that when seen for eye treatment in April 2001, the veteran reported a history of cataracts. He complained of trouble seeing when it is real bright outside and watering eyes. He reported a negative history of macular degeneration, glaucoma, eye surgery, eye injuries, and diabetes. He noted that he wears glasses, and it had been three years since his last prescription change. The RO asked another examiner to review the file, including the prior examination reports, for the purpose of providing an opinion. The review was completed in April 2001. The examiner reported impressions of markedly decreased visual acuity mainly based on bilateral disease of the macula, and possible early posterior subcapsular cataracts in both eyes. Specific evidence of ocular disease was not found. The examiner pointed out that based on the findings stated in the May 1994 letter, the first indication of an ocular or visual problem was in 1994. He stated that the findings of cataracts documented in the May 1994 letter were "thrown into confusion" by a later VA hospital note which reflects a finding of clear lens bilaterally, but supports the presence of significant macular lesions of both eyes. As a result of that visit, the veteran was seen by a retinal specialist in November 1994 who ultimately determined that the condition is hereditary in nature. The examiner noted that certain systemic drugs can cause changes in the retina of both eyes, and that a review of the records dated back to the 1980s, failed to disclose any drugs that might cause such changes in the retina were used in the veteran's case. He then determined that the retina specialist's opinion would hold with regard to a hereditary form of macular dystrophy and retinal dysfunction. The examiner then compared the visual acuity findings recorded by several examiners. Regarding the finding of Laber's disease in 1999, the examiner determined that the history and presentation were not any form of the disease. The examiner found that the January 2001 fluorescein angiogram report stated that it is possible that retinal atrophy associated with steroid treatment for Crohn's disease was showing up on the examination. The examiner opined that steroids are not the type of drugs associated with macula changes, and have not been the problem of the sort seen with regard to the veteran. It was determined that the veteran suffers from macular dystrophy that affects his macula and retina, and that the disease process accounts for his poor vision. The examiner stated the belief that the first notice of the decreased vision was in adulthood, and it was first documented in 1994. The examiner expressed uncertainty as to whether the veteran suffers from cataracts, but did point out that the optometrist carefully described them in 1994. The examiner commented that on later examinations cataracts were not reported. However, the examiner opined that if the veteran does in fact have cataracts of the posterior subcapsular type, then he would certainly say that the development of these cataracts could be related to high dosage systemic cortisone therapy used to treat the veteran's Crohn's disease. Although he stated such an opinion, the examiner further opined that he was totally unable to associate the macular/retinal disease with the use of steroids or other drug therapy. The examiner also expressed his regret with respect to his inability to be more definite. VA records associated with the file include a November 2002 ophthalmology consult. The history of Crohn's disease, treatment by a private physician, and complaints of photosensitivity and decreased vision were noted. On that day, the veteran complained of an increase in symptoms such as burning, watering, and light sensitivity over the past years since his diagnosis of Crohn's disease. The following was revealed on examination: visual acuity of count fingers at three feet for both eyes; normal pressure and slit-lamp examination; no inflammation in either eye; significant retinal pigment epithelium atrophy in both eyes on dilated fundus examination; and hemorrhages or fluid not present. The examiner reported the presence of central retinal atrophy of unknown etiology, but in keeping with macular degeneration. Regarding light sensitivity, the examiner found that neither eye had any evidence of inflammation, and advised the veteran to continue using sunglasses. There was mild conjunctivitis of both eyes, and the veteran was instructed to use Vasocon drops and artificial tears. Criteria Service connection may be granted for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2002); Allen v. Brown, 7 Vet. App. 439 (1995). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3 (2002). The Secretary shall consider all information and lay and medical evidence of related in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. Analysis Preliminary Matter: Duty to Assist The Board notes that during the pendency of this appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. This liberalizing law is applicable to this appeal. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). To implement the provisions of the law, the VA promulgated regulations published at 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)). The Act and implementing regulations essentially provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. It also includes new notification provisions. In regard to fulfilling VA's duty to assist the veteran under the VCAA, the Board notes that further development is not necessary in view of the favorable decision that follows. In this regard, the Board notes that any deficiencies which may exists in the duties to notify and to assist the veteran in the development of his claim constitute harmless error. In other words, the veteran will not be prejudiced by the Board proceeding to a decision in this matter since the outcome represents a full grant of the benefits being sought. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Secondary Service Connection Service connection is currently in effect for Crohn's disease, and the medical records associated with the claims folder show that steroids were used to treat the condition in 1994. The medical documentation of record shows that the veteran had not been diagnosed with eye disorders prior to 1994. Therefore, based on a longitudinal review of the record, it is reasonable to conclude that the current eye disorders developed after the occurrence of and treatment for Crohn's disease in the 1990s. This is confirmed by the VA examiner's assessment of April 2001, wherein he found that the veteran's problems with decreased vision were in adulthood and first documented in 1994. The CAVC has held that where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to render a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). The VA examiner did not relate macular/retinal disease to the use of steroids or other drug therapy. However, he did acknowledge the possibility of a relationship between the steroids used to treat the veteran's Crohn's disease and the occurrence of cataracts. Clearly from the comments in the report, the VA examiner felt that the findings recorded subsequent to those in May 1994 created some confusion, but did support the presence of significant macular lesions of both eyes. Although the VA examiner was not certain if the veteran suffers from cataracts, his comments indicate that he deferred to the private physician as that physician "carefully described" the condition in the May 1994 letter. As presented in the Factual Background above, in May 1994, the private physician who had an opportunity to examine the veteran, associated the developing posterior subcapsular cataracts with the use of steroids. Overall, the medical evidence is sufficient to show that following treatment of service-connected Crohn's disease with steroids, the veteran developed cataracts in 1994, thereby warranting entitlement to a grant of service connection on a secondary basis. ORDER Entitlement to service connection for bilateral cataracts as secondary to the administration of steroids for treatment of service-connected Crohn's disease is granted. ____________________________________________ RONALD R. BOSCH Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.