Citation Nr: 1125215 Decision Date: 07/05/11 Archive Date: 07/14/11 DOCKET NO. 07-34 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for strokes, to include as secondary to medication taken for service-connected erectile dysfunction and depression. 2. Entitlement to service connection for left eye vision loss, to include as secondary to medication taken for service-connected erectile dysfunction and depression. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from June 1963 to August 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to service connection for hypertension, to include as secondary to medications taken for service-connected erectile dysfunction, has been raised by the record (see October 2007 VA Form 9), but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this issue, and it is referred to the AOJ for appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Although the Board sincerely regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims. Remand is required to obtain clarification of VA examinations. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A mere medical conclusion is insufficient to permit the Board to make an informed decision regarding the probative value of that opinion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). Furthermore, a medical opinion should generally address all appropriate theories of entitlement. Stefl, 21 Vet. App. at 123-24. The Veteran claims entitlement to service connection for strokes and left eye vision loss, to include as secondary to medications taken for his service-connected erectile dysfunction and depression. In an April 2006 examination report, a VA ophthalmologist stated that for the issue of bilateral eye condition secondary to depression and stroke, the left eye vision loss was as likely as not caused by non-service-connected hypertension. The examiner also stated that the Veteran should not take Viagra and should work to control his hypertension. In an April 2006 VA medical examination, the VA physician stated that regarding the claimed condition of stroke, the diagnosis was cerebrovascular accident, residual vision loss. No opinion as to any nexus between the stroke and medications for the service-connected disabilities was provided. In a June 2006 addendum, the VA physician noted that the ophthalmologist evaluation states occlusion of central retina, vein, left eye, as likely as not secondary to hypertension. The physician noted that he agreed with the assessment, less likely than not secondary to erectile dysfunction/Viagra. Thus, although the ophthalmologist recommended that the Veteran not take Viagra, no opinion was provided regarding whether the vision loss was caused or aggravated by the Veteran's medications, as opposed to the service-connected conditions themselves. Additionally, the ophthalmologist did not provide any rationale for the opinion that the vision loss was caused by hypertension. The physician stated that he agreed with the ophthalmologist that the strokes were not related to erectile dysfunction and Viagra, but the ophthalmologist did not address Viagra. Further, the physician did not provide any rationale for the provided opinion. Thus, neither medical opinion is adequate and remand is required to obtain the necessary medical opinions. At the hearing in April 2001, the Veteran indicated that in 2006 he was referred by his VA doctor to an outside private physician regarding his vision loss and he received treatment, including an injection. He was unable to recall the name of the medical facility and indicated that physician was Dr. Lane. The record was held open for 30 days to allow him to attempt to obtain those records, but none have been submitted. The RO should contact the Veteran and request that he attempt to better identify that treatment and, sufficient identification is provided, obtain those records. In addition, he indicated that he was receiving ongoing treatment at the Houston VA medical center and updated treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Contact the Houston VA Medical Center and obtain and associate with the claims file all outstanding records of treatment, to include records dated after September 2007. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. 2. Contact the Veteran and request that he provide more complete identification of private treatment related to his vision condition in 2006, as indicated during the hearing in April 2006. If sufficient identification is provided, the RO should attempt to obtain those private treatment records. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. 3. Request an addendum opinion from the same VA examiner who conducted the April 2006 ophthalmology examination. If the examiner determines that a new examination is required, one must be conducted. If the same examiner is not available, the AMC must afford the Veteran a new comprehensive examination to determine the etiology of the Veteran's left eye vision loss. Regardless of whether an examination is conducted, the claims folder, including a copy of this remand, must be made available to the examiner. All clinical findings must be reported in detail and correlated to a specific diagnosis. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the examination report, and a rationale provided for that conclusion. The examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record whether it is more or less likely than not that the Veteran's left eye vision loss was caused or aggravated by the medication that the Veteran took for his service-connected erectile dysfunction and depression. The examiner must specifically address the notation in the April 2006 VA ophthalmology examination report that the Veteran should not take Viagra. The examiner must also provide a rationale for the previously provided opinion that the left eye vision loss was as likely as not related to hypertension. 4. Request an addendum opinion from the same VA examiner who conducted the April 2006 medical examination. If the examiner determines that a new examination is required, one must be conducted. If the same examiner is not available, the AMC must afford the Veteran a new comprehensive examination to determine the etiology of the Veteran's stroke. Regardless of whether an examination is conducted, the claims folder, including a copy of this remand, must be made available to the examiner. All clinical findings must be reported in detail and correlated to a specific diagnosis. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the examination report, and a rationale provided for that conclusion. The examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record whether it is more or less likely than not that the Veteran's stroke was caused or aggravated by the medications taken for his service-connected depression and erectile dysfunction. The examiner must specifically address the notation in the April 2006 VA medical examination addendum that the stroke was less likely than not secondary to erectile dysfunction and Viagra. 5. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 6. Review the examination reports to ensure that they are in complete compliance with the directives of this remand. If the reports are deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. 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. 2010). _________________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This 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) (2010).