Citation Nr: 0620890 Decision Date: 07/18/06 Archive Date: 07/26/06 DOCKET NO. 04-37 319 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for hypertensive arteriosclerotic cardiovascular disease, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for arthritis of the hands, toes, elbows, knees, and shoulders, to include as secondary to service-connected diabetes mellitus. 3. Entitlement to service connection for bilateral cataracts, to include as secondary to service-connected diabetes mellitus. 4. Entitlement to an increased initial rating for diabetes mellitus, currently rated as 20 percent disabling. 5. Entitlement to a compensable rating for diabetic retinopathy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Simone C. Krembs, Associate Counsel INTRODUCTION The veteran served on active duty from November 1966 to November 1986. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) that granted the veteran's claim for diabetes mellitus with nonproliferative retinopathy, and awarded a 20 percent disability rating, effective July 9, 2001, and denied the veteran's claims for service connection for hypertensive arteriosclerotic cardiovascular disease; service connection for arthritis of the hands, toes, elbows, knees, and shoulders; and bilateral cataracts, each to include as secondary to service-connected diabetes mellitus. In June 2005, the veteran testified before the Board at a hearing that was held at the RO. The claims for a compensable rating for diabetic retinopathy and for bilateral cataracts are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The veteran has hypertensive arteriosclerotic cardiovascular disease (cardiovascular disease) that is related to and is aggravated by his service-connected diabetes mellitus. 2. The veteran does not have a current diagnosis of arthritis in the toes, elbows, or left shoulder. 3. The veteran's degenerative joint disease (arthritis) of the hands, knees, and right shoulder first manifested many years after service and is unrelated to any aspect thereof, including his service-connected diabetes mellitus. 4. The veteran's service-connected diabetes mellitus is manifested by the need for daily oral hypoglycemic agents and dietary restrictions, but his physical activity has not been clinically regulated. CONCLUSIONS OF LAW 1. The veteran's cardiovascular disease is aggravated by the veteran's service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310(a) (2005). 2. Claimed arthritis of the toes, elbows, and left shoulder was not incurred in or aggravated by the veteran's active service. 38 U.S.C.A. §§ 1131; 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2005). 3. Arthritis of the hands, knees, and right shoulder was not incurred in or aggravated by the veteran's active service, and is not proximately due to or the result of his service- connected diabetes mellitus. 38 U.S.C.A. §§ 1110; 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2005). 4. The criteria for a rating higher than 20 percent for diabetes mellitus have not been met since July 9, 2001, the effective date of service connection. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913 (2005). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2005). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Service connection for certain chronic diseases, including cardiovascular disease and arthritis, will be rebuttably presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2005). 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (2005). For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2005). A disability which is proximately due to or the result of a service-connected disease or injury shall be service- connected. 38 C.F.R. § 3.310 (2005). Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service." Watson v. Brown, 309, 314 (1993). Establishing service connection on a secondary basis essentially requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either caused or aggravated by a service- connected disability. 38 C.F.R. § 3.303, 3.310. The veteran contends that he is entitled to service connection for hypertensive arteriosclerotic cardiovascular disease, and arthritis of the hands, toes, elbows, knees, and shoulders, each to include as secondary to service-connected diabetes mellitus. The Board will address these claims in turn. A. Cardiovascular Disease The veteran's service medical records are negative for any diagnosis or treatment of cardiovascular disease with the exception of a single complaint of tachycardia in February 1977. The veteran was not diagnosed with hypertension or any other cardiovascular condition. On examination prior to separation, no cardiovascular abnormality was found. As the veteran did not receive any additional treatment for any cardiovascular complaints, and no abnormality was noted on separation, the Board finds that the weight of the evidence does not establish chronicity in this case. 38 C.F.R. § 3.303 (2005). As chronicity in service has not been established, a showing of continuity of symptoms after discharge is required to support the veteran's claims for service connection of his cardiovascular disease. 38 C.F.R. § 3.303(b). The veteran's post-service medical records indicate that he was first diagnosed with hypertension by his private primary care physician in September 2002. The physician has not opined as to whether the veteran's cardiovascular disease is related to his period of active service or to his service-connected diabetes mellitus, as the veteran contends. The veteran underwent VA cardiovascular examination in January 2003, July 2004, and October 2004. On examination in January 2003, the veteran reported experiencing pricking chest pain for the past few years, and stated that he was hypertensive but not taking medication for control of that condition. As a result of the examination, the veteran was diagnosed with hypertensive arteriosclerotic cardiovascular disease. In a February 2003 addendum to the report of examination, the examiner noted that the veteran's latest examination for his diabetes mellitus condition did not show any form of retinopathy. The absence of any retinopathy, combined with the fact that the veteran's cardiovascular disease and diabetes mellitus were diagnosed less than five years apart, made it unlikely that the heart condition was a direct complication of the diabetes. Rather, the veteran's dyslipidemia and hypertension were the more likely contributory factors to the veteran's development of hypertensive arteriosclerotic cardiovascular disease. The veteran was scheduled for an additional cardiovascular examination in July 2004, as a result of which he was diagnosed with hypertension and hypertensive arteriosclerotic cardiovascular disease with concentric left ventricular hypertrophy. The examiner did not opine as to whether the veteran's cardiovascular disease is related to his period of active service or to his service-connected diabetes mellitus. The veteran underwent VA examination for his diabetes mellitus condition in July 2004 with the same examiner who conducted the July 2004 cardiac examination. In her report of examination, the examiner stated that long-standing diabetes mellitus hastens atherosclerosis which may give rise to hypertension. Here, the veteran's diabetes mellitus was diagnosed in 1999, although he could have had subclinical diabetes prior to 1999 that was not diagnosed. The undiagnosed diabetes mellitus could have hastened the formation of hypertension and atherosclerosis. Because it was difficult in this case to pinpoint whether the veteran's hypertension or diabetes mellitus developed first, it was as likely as not that the hypertensive arteriosclerotic cardiovascular disease was secondary to the diabetes mellitus. In order to resolve the conflicting February 2003 and July 2004 opinions as to the etiology of the veteran's cardiovascular disease, an additional examiner reviewed the veteran's claims file in October 2004 prior to rendering an opinion. The examiner at that time found that the veteran's cardiovascular disease was not likely a direct complication of his diabetes mellitus, but that it was likely aggravated by the diabetes mellitus. The rationale for this opinion was that the microvascular complications of diabetes mellitus and hypertension, noted in the retina and kidneys, precede the macrovascular complications of diabetes mellitus, such as coronary artery disease or atherosclerosis in the major arteries. Microvascular complications will be delayed if the patient's blood pressure and blood sugar levels are well controlled. In this case, the veteran's latest opthamologic test results revealed diabetic retinopathy, but not hypertensive retinopathy, indicating that his diabetes mellitus was poorly controlled. The examiner found that the presence of coronary artery disease, heart enlargement, and atherosclerosis in the veteran were due to multiple factors, including diabetes mellitus, hypertension, and dyslipidemia that led to endothelial cell damage. Here, the onset of the veteran's diabetes and hypertension were at most five years apart, and were poorly controlled. Microvascular complications such as diabetic retinopathy and nephropathy can be detected as early as five years from the onset of the diabetes mellitus if the condition is poorly controlled. If the veteran did not have hypertension or dyslipidemia, his atherosclerosis may have presented much later. Given the veteran's likely state of insulin resistance, however, it was more likely than not that the veteran's diabetes mellitus, dyslipidemia, and hypertension shared a common pathophysiology, which led to the atherosclerosis, but not the other way around. Thus, the veteran's cardiovascular disease was not likely a direct complication of his diabetes mellitus, but it was likely aggravated by the diabetes mellitus. Here, the first post-service clinical evidence related to the veteran's cardiovascular disease is dated in September 2002, many years after his separation from service. He is accordingly not entitled to service connection on a presumptive basis. Additionally, in view of the lengthy period without treatment, there is no evidence of a continuity of symptomatology, and this weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). However, the veteran does not contend that his cardiovascular disease is a result of his active service, but rather that it is related to his service-connected diabetes mellitus. Specifically, he contends that his diabetes mellitus has aggravated his cardiovascular disease. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App. 140 (1993). A causal link is not required for service connection on a secondary basis. A showing that the service-connected disability aggravates the condition at issue will also satisfy the requirements for service connection on a secondary basis. Allen v. Brown, 7 Vet. App. 439 (1995). In such cases, however, only the portion attributable to the service-connected condition will qualify for compensation. In this case, the October 2004 examiner clarified the July 2004 examiner's finding that there was a relationship between the veteran's diabetes mellitus and his cardiovascular disease by stating that the veteran's poorly controlled diabetes mellitus hastened his development of atherosclerosis, and thus his cardiovascular disease was aggravated by his service-connected diabetes mellitus. In considering the October 2004 examiner's opinion, along with the other opinions of record, the Board finds it at least as likely as not that the veteran's cardiovascular disease is aggravated by his service-connected diabetes mellitus. As such, the Board concludes that the veteran's claim for entitlement to service connection for hypertensive arteriosclerotic cardiovascular disease, as secondary to his service-connected diabetes mellitus, is warranted. Hanson v. Derwinski, 1 Vet. App. 512 (1991). B. Arthritis The veteran contends that he is entitled to service connection for arthritis of the hands, toes, elbows, knees, and shoulders. He does not contend either that he first developed arthritis in service, or that he injured himself during service, but rather that he has developed arthritis after service as a result of his service-connected diabetes mellitus. The veteran's service medical records are silent as to any orthopedic complaints, including findings of arthritis. The Board therefore finds that the weight of the evidence does not establish chronicity in this case. 38 C.F.R. § 3.303 (2005). As chronicity in service has not been established, a showing of continuity of symptoms after discharge is required to support the veteran's claim for service connection. Post- service medical records show that the veteran received private treatment for arthritis of the hands beginning in February 2003 and for arthritis of the right shoulder beginning in 2004. The veteran contends that his joints began hurting many years before this but that he did not seek medical attention. A January 2003 VA examination of the joints revealed arthritis of the hands and knees, bilaterally, and of the right shoulder. No arthritis was found in the toes, elbows, or left shoulder. Neither the veteran's private physician nor the VA examiner opined as to whether the arthritis in the veteran's hands, knees, or right shoulder was related to his period of active service or to his service-connected diabetes mellitus. Here, the first post-service X-ray evidence of arthritis in the hands, knees, and right shoulder is dated in February 2003, many years after the veteran's separation from service. He is accordingly not entitled to service connection on a presumptive basis. Additionally, in view of the lengthy period without treatment, there is no evidence of a continuity of symptomatology, and this weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Service connection may be granted when all the evidence establishes a medical nexus between military service and current complaints. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In this case, there is no probative evidence establishing a medical nexus between military service and the veteran's arthritis of the hands, knees, and right shoulder. Thus, service connection on a direct basis is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Nor is service connection on a secondary basis warranted, as no relationship between the veteran's arthritis and his service- connected diabetes mellitus has been found. Additionally, as there is no evidence of arthritis in the toes, elbows, or left shoulder, the claim for service connection for arthritis in those joints must be denied. Specifically, the veteran's service medical records and post- service VA medical records reflect no diagnosis of arthritis of the toes, elbows, or left shoulder. Absent evidence of a current disability, service connection for arthritis of the toes, elbows, and left shoulder must be denied. The Board has considered the veteran's claims that he had arthritis of the toes, elbows, and left shoulder, and his contentions as to the etiology of the arthritis in his hands, knees, and right shoulder. However, as a layperson, the veteran is not competent to give a medical opinion on causation or aggravation of a medical condition. See Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). While the veteran can describe symptoms (including worsening of symptoms) that he experiences, he lacks the medical competence to relate those symptoms to his service, or to his service-connected diabetes mellitus. As the preponderance of the evidence is against the claims for service connection for arthritis of the hands, toes, knees, elbows, and shoulders, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2005). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in this case the veteran timely appealed the rating initially assigned for this disability on the original grant of service connection. The Board must therefore consider entitlement to "staged ratings" for different degrees of disability in the relevant time periods, that is, since the original grant of service connection. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities (hereinafter "Rating Schedule"), which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2005). A 20 percent rating is warranted for diabetes mellitus requiring insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913 (2005). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process under DC 7913. 38 C.F.R. § 4.119, DC 7913, Note (1) (2005). The veteran asserts that a rating greater than 20 percent is warranted under DC 7913 because his diabetes mellitus is worse than the assigned rating provides. Having carefully considered the veteran's claim in light of the record and the applicable law, the Board concludes that the preponderance of the evidence is against the claim, and the appeal will be denied. The veteran was diagnosed with diabetes mellitus in 1999. A record of his initial diagnosis is not in the claims folder. According to VA and private examiners, the veteran's diabetes mellitus is under poor control. The veteran has been advised to follow a restricted diet for control of his diabetes mellitus. This diet consists of restricted calories and a low fat, low sugar, and low salt regimen. The veteran takes oral hypoglycemic agents to control his diabetes mellitus. His dosages have increased periodically since the initial prescription. He has not been prescribed insulin injections as a part of his control regimen. In addressing the third criterion for a higher rating, there is no evidence in this case that the veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. See 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). On examination in September 2002, the veteran stated that he regularly jogged. While the August 2004 VA examiner noted that the veteran avoided strenuous activities after taking his medication for diabetes, it does not appear that the veteran has been advised to limit his physical activity; indeed, physical activity has been encouraged. In order to meet a higher rating of 40 percent, the veteran must have been told that he should avoid any strenuous occupational or recreational activities. See 38 C.F.R. § 4.119, DC 7913 (emphasis added). The veteran has stated that his diabetes disability makes him less active than he used to be, and that he is easily winded. The more recent evidence does show that the veteran tires easily. However, the level of the veteran's physical activity is not the appropriate standard by which to judge whether his activities are regulated. While the veteran attributes his low level of activity to his diabetes, he, as a layperson, is not competent to provide a medical opinion as to the severity of his diabetes disability, including whether he is or is not capable of, or must avoid, strenuous occupational and recreational activities, due to diabetes. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The available evidence does not indicate that the veteran has been prescribed or advised to avoid strenuous occupational and recreational activities, as is required in order to merit a higher rating of 40 percent. While the veteran here has been prescribed a restricted diet and oral hypoglycemic agents in effort to control his diabetes, he has not been prescribed insulin or limited physical activity or advised to avoid recreational activities. The veteran therefore does not meet the criteria for a higher rating of 40 percent. 38 C.F.R. § 4.119, DC 7913. As the preponderance of the evidence is against the claim for a higher rating, the "benefit-of-the-doubt" rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 50 (1990). The Board finds that, since the effective date of service connection, there were no distinct periods of time during which the veteran's diabetes mellitus was more than 20 percent disabling. He is accordingly not entitled to receive a "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Duties to Notify and Assist the Appellant Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 3.159 (2005). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim, or something to the effect that the claimant should "give us everything you've got pertaining to your claim(s)." Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO sent correspondence in February 2002, October 2002, September 2003, March 2004, July 2004, and September 2004; rating decisions in November 2002, February 2003, and November 2004; a statement of the case in July 2004; and a supplemental statement of the case in November 2004. These documents discussed specific evidence, the particular legal requirements applicable to the claims, the evidence considered, the pertinent laws and regulations, and the reasons for the decisions. VA made all efforts to notify and to assist the appellant with regard to the evidence obtained, the evidence needed, the responsibilities of the parties in obtaining the evidence, and the general notice of the need for any evidence in the appellant's possession. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. There has been no prejudice to the appellant, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the final adjudication in the February 2005 supplemental statement of the case. In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has also obtained multiple medical examinations in relation to these claims. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. ORDER Service connection for hypertensive arteriosclerotic cardiovascular disease is granted. Service connection for arthritis of the hands, toes, knees, elbows, and shoulders is denied. A rating greater than 20 percent for diabetes mellitus is denied. REMAND Additional development is needed prior to further disposition of the claims for service connection for bilateral cataracts and for a compensable rating for diabetic retinopathy. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion only when it is deemed necessary to make a decision on the claim. A medical examination or opinion is necessary to make a decision on a claim if all of the lay and medical evidence of record (1) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (2) indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but (3) does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) (2005). The veteran underwent VA examinations of the eyes in September 2002, January 2004, June 2004, and December 2004. At these examinations, the examiners addressed eye conditions including cataracts and diabetic retinopathy. The Board finds that an additional examination and opinion are needed with regard to the veteran's bilateral cataracts. The veteran contends that he has developed bilateral cataracts secondary to his service-connected diabetes mellitus. Post- service medical records show that the veteran was diagnosed with a beginning cataract in the left eye in September 1999. A November 1999 private treatment record notes that the beginning cataract in the left eye is probably secondary to diabetes mellitus. VA examinations dated in September 2002, January 2004, June 2004, and December 2004 diagnosed immature cataracts of both eyes, but the examiners did not opine as to whether the opacities were related to the veteran's diabetes mellitus. The Board, however, finds the November 1999 private opinion stating that the veteran's cataract was probably related to his diabetes mellitus to be speculative and require a greater explanation of reasoning. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not" exist or "may or may not" be related, is too speculative to establish the presence of a claimed disorder or an such relationship). In addition, that opinion only addressed one eye, while the cataracts are shown to be bilateral. As a VA examiner has not yet opined as to whether the veteran's bilateral cataracts are related to his service- connected diabetes mellitus, the Board finds that an additional examination and opinion as to the likely etiology are necessary. Finally, the Board finds that an additional examination addressing the nature and severity of the veteran's diabetic retinopathy is necessary. At his June 2005 hearing before the Board, the veteran alleged that his diabetic retinopathy had worsened. When available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). Although the last VA examination of the eyes is not unduly remote, the veteran has indicated that his condition has worsened since the date of the latest treatment of record. Because there may have been a significant change in the condition of the veteran's diabetic retinopathy disability, the Board finds that a new examination is in order. Accordingly, the claim is REMANDED for the following actions: 1. Schedule the veteran for a VA opthamological examination. The physician should review the record and render an opinion as to whether it is as likely as not (50 percent or more probability) that the veteran's cataracts are due to or aggravated by his service-connected diabetes mellitus. The examiner should also describe the current nature and severity of the veteran's diabetic retinopathy and the extent to which the diabetic retinopathy impairs his visual acuity. The examiner should also state whether the retinopathy results in, contributes to, or aggravates any other opthamological impairment. The examiner should indicate that the claims folder has been reviewed and discuss the private and VA medical records of prior treatment for cataracts and diabetic retinopathy. The examiner should specifically address and reconcile this opinion with the November 1999 opinion finding that the veteran's cataract was probably secondary to diabetes mellitus. If the examiner feels that the requested opinion cannot be given without resort to speculation, the examiner should so state. 2. Then, after ensuring any other necessary development has been completed, readjudicate the claims for service connection for bilateral cataracts and for a compensable rating for diabetic retinopathy. If further action remains adverse to the veteran, provide the veteran and his representative with a supplemental statement of the case and allow the appropriate opportunity to respond thereto. Thereafter, the case should be returned to this Board. The appellant has the right to submit additional evidence and argument on the matters the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2005). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs