Citation Nr: 1412612 Decision Date: 03/25/14 Archive Date: 04/02/14 DOCKET NO. 11-01 115 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for type II diabetes mellitus, to include as due to the claimed in-service herbicide or chemical exposure. 2. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to type II diabetes mellitus. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to type II diabetes mellitus. 4. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to type II diabetes mellitus. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to type II diabetes mellitus. 6. Entitlement to service connection for erectile dysfunction, to include as secondary to type II diabetes mellitus. 7. Entitlement to service connection for glaucoma, to include as secondary to type II diabetes mellitus. 8. Entitlement to service connection for a skin disorder, to include as secondary to herbicide or chemical exposure or as secondary to type II diabetes mellitus. REPRESENTATION Appellant represented by: Theodore C. Jarvi, Attorney ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1975 to December 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Detroit, Michigan, Department of Veterans Affairs (VA). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the file on the "Virtual VA" system to ensure a complete assessment of the evidence. Subsequent to the issuance of the April 2013 Supplemental Statement of the Case, the Veteran's representative submitted additional statements and evidence in June 2013, for which a waiver of initial RO consideration was provided. The issues on appeal were previously remanded by the Board in August 2011 for further evidentiary development and to obtain a VA examination for the Veteran's skin disorder. This was accomplished, and the claims were readjudicated in an March 2013 supplemental statement of the case. The issues of service connection for a glaucoma and a skin disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO. The issues of service connection for dyslipidemia, hypertension, and hepatomegaly, to include as due to in-service chemical exposure or as secondary to type II diabetes mellitus have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran was exposed to toxic chemicals other than herbicides (Agent Orange) while stationed at Camp Carroll in Korea. 2. The Veteran has currently diagnosed type II diabetes mellitus, peripheral neuropathy of the upper and lower extremities, and erectile dysfunction. 3. Currently diagnosed type II diabetes mellitus is etiologically related to the in-service exposure to toxic chemicals. 4. Currently diagnosed peripheral neuropathy of the upper and lower extremities and erectile dysfunction are caused by the service-connected diabetes mellitus disability (granted herein). CONCLUSIONS OF LAW 1. The criteria for service connection for type II diabetes mellitus as a result of in-service chemical exposure have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for peripheral neuropathy of the right lower extremity as secondary to type II diabetes mellitus, have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 3. The criteria for service connection for peripheral neuropathy of the left lower extremity as secondary to type II diabetes mellitus, have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 4. The criteria for service connection for peripheral neuropathy of the right upper extremity as secondary to type II diabetes mellitus, have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 5. The criteria for service connection for peripheral neuropathy of the left upper extremity as secondary to type II diabetes mellitus, have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 6. The criteria for service connection for erectile dysfunction as secondary to type II diabetes mellitus, have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The claims of service connection for diabetes, peripheral neuropathy, and erectile dysfunction have been considered with respect to VA's duties to notify and assist. Given the favorable outcome of this decision (grant of service connection for diabetes, peripheral neuropathy, and erectile dysfunction), no conceivable prejudice to the Veteran could result from this decision. Further, as noted above, the remaining issues on appeal (service connection for glaucoma and for a skin disorder) are being remanded. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1131; 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). The conditions of diabetes mellitus and peripheral neuropathy (organic disease of the nervous system) are considered "chronic disease[s]" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). On the other hand, erectile dysfunction is not a chronic disease under 38 C.F.R. § 3.309(a) and will therefore be adjudicated using the general principles of service connection. Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The law and applicable regulatory provisions pertaining to Agent Orange exposure, expanded to include all herbicides used in Vietnam, provide that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). A veteran who during active military, naval, or air service, served between April 1, 1968 and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv) . The law and regulations further stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. § 3.309(e). Where a veteran was exposed to an herbicide agent during active military, naval, or air service in the Republic of Vietnam or in or near the Korean DMZ during the applicable time period, the following diseases shall be service connected, even though there is no record of such disease during service: chloracne, or any other acneform disease consistent with chloracne; type II diabetes (also known as Type II diabetes mellitus, or adult-onset diabetes); Hodgkin's disease; ischemic heart disease, including, but not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease, including coronary artery disease (including coronary spasm) and coronary bypass surgery, and stable, unstable, and Prinzmetal's angina; multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (i.e., cancers of the lung, bronchus, larynx, or trachea); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); or soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The foregoing diseases shall be service connected if a veteran was exposed to a herbicide agent during active military, naval, or air service, if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) and/or (iv) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. The presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era or in or near the Korean DMZ during the specified time period is not warranted for any condition other than those for which the Secretary of VA has specifically determined that a presumption of service connection is warranted. 38 U.S.C.A. § 1116. In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, but must also determine whether his current disability is the result of active service. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Type II Diabetes Mellitus The Veteran contends that currently diagnosed type II diabetes mellitus is related to in-service chemical exposure and/or Agent Orange exposure. See representative's statement dated June 2013. The Veteran has consistently maintained that he served as a heavy equipment operator during service and was charged with excavating a large ditch at Camp Carroll, Korea in 1978. He has also stated that he was required to dump barrels (some of which were leaking) into the ditch. The Veteran reported that one barrel in particular, broke, and the contents spilled onto his lower body. Initially, the Board finds that the Veteran has been diagnosed with type II diabetes mellitus since approximately 1994. See VA treatment record dated July 2011 in Virtual VA. Next, the Board finds that the Veteran is not presumed to have been exposed to Agent Orange during service. While the Veteran has an Agent Orange presumptive disease (diabetes mellitus), he did not serve in the Republic of Vietnam or during the period of use of herbicides in Korea when herbicides were being applied. In this regard, the Veteran does not maintain that he served in Vietnam. Also, the Veteran did not serve in Korea between April 1, 1968 and August 31, 1971, which is the period determined by the Department of Defense presumed to have been exposed to an herbicide agent. See 38 C.F.R. § 3.307(a)(6)(iv). As noted above, the Veteran was on active duty from December 1975 to December 1979. Therefore, his diabetes mellitus is not presumed to be related to Agent Orange exposure in Korea. That notwithstanding, the Board finds that the evidence is in equipoise as to whether the Veteran was exposed to toxic chemicals, other than Agent Orange, during his service in Korea. Although the Veteran has maintained that his service responsibilities in Korea included the burial of Agent Orange, he has also consistently stated that Agent Orange was only one type of refuse that he was assigned to bury at Camp Carroll. Following the Veteran's allegations, the Army conducted an extensive investigation that concluded that the Camp Carroll site had been used to bury numerous chemicals, but not Agent Orange. The report from the Camp Carroll Task Force dated December 2011 found that drums of pesticides, herbicides, and solvents--not Agent Orange--were buried in Area D in 1978, but that these materials were later excavated with a large quantity of soil from 1979 to 1980 and shipped to an unidentified location. This was verified by in an interview with the former transportation officer for Camp Carroll in 1979. He specifically described the preparation that was undertaken to ship chemicals that had been excavated from a burial site on Camp Carroll, including 800 drums to "repackage" the excavated chemicals. An Executive Summary of the Army's Comprehensive Report for Agent Orange at Camp Carroll in Korea denied that there had been Agent Orange at the Camp Carroll site; however, it did provide a list of chemicals identified there in 2011, including: pesticides and volatile organic compounds (VOCs) such as PCE, TCE, benzene, 1,2,4 trimethylbenzen, and 1,2,2,2-tetrachlroethane. These chemicals were noted to have been detected in some groundwater and soil samples. The Veteran has also submitted numerous buddy statements from fellow service-members which appear to corroborate the Veteran's assertions and the Army report regarding burying of chemical material at Camp Carroll. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran was exposed to chemicals, other than Agent Orange, during service in Korea. Next, the Board finds that currently diagnosed type II diabetes mellitus is etiologically related to the in-service chemical exposure. The evidence of record includes a February 2013 opinion from Dr. S.B., an occupational and environmental physician. Dr. S.B. interviewed the Veteran and reviewed the report from the 2011 Camp Carroll Task Force listed above. Dr. S.B. also reviewed an unclassified 2004 report from the Eight Army Corp of Engineers. See 2004 Camp Carroll Area 4 and Area 41 Site Investigation Executive Summary at http://8tharmy.korea.army.mil/2004siteinvestigation.asp (copy of Executive Summary has been associated with the claims file). In this report, Camp Carroll was identified as a former drum storage area. The report further noted that these drums contained a variety of chemicals, including pesticides (DDT), herbicides, solvents, vehicle fluids (battery acid and antifreeze), POLs, other hydrocarbons, and other chemicals. Numerous spill events reportedly occurred in this area between 1976 and 1981. Eye-witness accounts describing soil discoloration and localized ponding of liquids indicate that a significant amount of leakage and spillage of materials had apparently occurred in the vicinity of stored containers. Upon review of this evidence, Dr. S.B. opined that, based on the Veteran's occupation and time served at Camp Carroll, it was as likely as not that the Veteran was exposed to dioxins, PCB's and possibly heavy metals which increased his risk of developing diabetes. Dr. S.B. further noted that dioxin exposure has been associated with several disease processes, including diabetes. The Eight Army Corp of Engineers Executive Summary Report of 2004 confirmed dioxins in surface soils at Camp Carroll. The Veteran also submitted a May 2013 medical opinion from Dr. J.B who is certified in endocrinology. Dr. J.B. reviewed the Dr. S.B.'s opinion, to include the Army reports, and concurred with Dr. S.B.'s opinion that environmental toxins, verified by the Army, more likely than not were etiologically related to developing diabetes. Citing the National Health and Examination Survey dated 1999-2002, Dr. J.B. noted that pesticides found at Camp Carroll were precisely the compounds shown to be associated with the development of insulin resistance and diabetes. The Board finds that the remaining evidence of record, to include VA treatment records, does not contradict the medical opinions provided from Dr. S.B. and Dr. J.B. The Veteran has not been afforded a VA examination for his diabetes disability. For these reasons, and upon review of all the evidence of record, both lay and medical, the Board finds that the weight of the evidence demonstrates that currently diagnosed diabetes is related to the verified in-service chemical exposure (not Agent Orange). Accordingly, service connection for type II diabetes mellitus as secondary to chemical exposure is warranted. Service Connection for Peripheral Neuropathy As noted above, service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The Veteran has currently diagnosed peripheral neuropathy of the hands and feet. See July 2011 and November 2013 VA treatment records in Virtual VA. Further, the Veteran is now, pursuant to this decision, service-connected for type II diabetes mellitus. The Board next finds that currently diagnosed peripheral neuropathy of the upper and lower extremities is etiologically related to the Veteran's diabetes disability. In a July 2011 VA diabetes clinic note, the VA physician noted that the Veteran's neuropathy of the upper and lower extremities were known diabetic complications. A November 2013 VA treatment record reflects a notation of "diabetic neuropathy," which indicates that the Veteran's bilateral neuropathy is related to diabetes. Further, a February 2008 statement from Dr. K.T. from the Joslin Diabetes Center noted that the Veteran had diabetes with complications, to include diabetic peripheral neuropathy. Dr. J.B's May 2013 medical opinion also found that diabetes was a likely contributor to the Veteran's neuropathic symptoms. The Board finds that the remaining evidence of record does not contradict the statements provided from Dr. K.T., Dr. J.B., and/or VA treatment records noting diabetic neuropathy of the upper and lower extremities. The Veteran has not been afforded a VA examination for his neuropathy. For these reasons, and upon review of all the evidence of record, both lay an medical, the Board finds that the weight of the evidence demonstrates that currently diagnosed peripheral neuropathy of the upper and lower extremities is related to the service-connected diabetes disability. Accordingly, service connection for peripheral neuropathy of the upper and lower extremities is warranted. Service Connection for Erectile Dysfunction VA treatment records reflect that the Veteran has been diagnosed with erectile dysfunction and is prescribed Viagra, a medication used to treat symptoms of erectile dysfunction. See VA treatment records in Virtual VA dated November 2013. Further, the Board finds that the Veteran's currently diagnosed erectile dysfunction is etiologically related to the service-connected diabetes disability. In a February 2008 statement from the Joslin Diabetes Center, Dr. K.T. noted that the Veteran had been under his care since 2006. It was noted that the Veteran had uncontrolled type II diabetes mellitus with complications, which included, in pertinent part, erectile dysfunction. For these reasons, the Board finds that the weight of the evidence demonstrates that currently diagnosed erectile dysfunction is related to the service-connected diabetes disability. As such, service connection for erectile dysfunction is warranted. (CONTINUED ON NEXT PAGE) ORDER Service connection for type II diabetes mellitus is granted. Service connection for peripheral neuropathy of the right lower extremity as secondary to the service-connected type II diabetes mellitus disability is granted. Service connection for peripheral neuropathy of the left lower extremity as secondary to the service-connected type II diabetes mellitus disability is granted. Service connection for peripheral neuropathy of the right upper extremity as secondary to the service-connected type II diabetes mellitus disability is granted. Service connection for peripheral neuropathy of the left upper extremity as secondary to the service-connected type II diabetes mellitus disability is granted. Service connection for erectile dysfunction as secondary to the service-connected type II diabetes mellitus disability is granted. REMAND Service Connection for Glaucoma The Veteran's VA treatment records reflect a long history of glaucoma. The Veteran has not been afforded a VA examination to address the etiology of the diagnosed glaucoma. VA treatment records and private medical opinions from Dr. J.B. and Dr. S.B. do not provide an opinion as to the etiology of the Veteran's glaucoma. Further, although Dr. K.T from the Joslin Diabetes Center noted that the Veteran had glaucoma, it was not specifically listed as a complication associated with diabetes. As such, the Board finds that the Veteran should be afforded a VA examination to assist in determining whether currently diagnosed glaucoma is related to service, to include as secondary to the now service-connected diabetes disability. Service Connection for a Skin Disorder The Veteran contends that he occasionally develops blisters on his hands, which break open and ooze fluid. According to the Veteran, these symptoms have persisted since service, to include his exposure to chemicals while stationed in Korea. Service treatment records only reveal treatment for a rash on the groin, and none pertaining to the hands. Pursuant to the August 2011 Board remand, the Veteran was afforded a VA skin examination in November 2011. The VA examiner diagnosed the Veteran with a chronic skin rash with unknown etiology. In a separate section of the examination, the VA examiner noted diagnoses of dermatitis and papulosquamous disorder. The VA examiner then stated that he was unable to determine the nature and etiology of the current skin rash and was unable to render an opinion regarding the skin rash. The Board finds the November 2011 VA medical opinion contradictory as to the Veteran's current skin diagnoses and inadequate as to the requested medical opinion. The Board notes that the February 2013 opinion from Dr. S.B. diagnosed the Veteran with porphyria variegate and stated that this disorder was just as likely as not related to exposure to dioxins in service; however, VA treatment records specifically contradict a diagnosis of porphyria variegate. In a December 2012 VA treatment record (in Virtual VA), the VA physician noted that the Veteran underwent a urine and serum porphyrin evaluation which provided negative results. Instead, the VA physician noted that the Veteran's skin disorder was consistent with psoriasis. For these reasons, the Board finds that a new VA examination is warranted in order to clarify the nature of the Veteran's current skin disorder and to provide a medical opinion with supporting rationale as to the etiology of any diagnosed skin disorder. Finally, the last VA treatment record is dated January 14, 2014 from the Detroit VA Medical Center. On remand, updated VA treatment records should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Obtain all treatment records from the Detroit VAMC from January 15, 2014 to the present. Any documents received by VA should be associated with the record. Any negative responses should be properly documented in the record. 2. After completing the above, schedule the Veteran for a VA eye examination to assist in determining the etiology of his currently diagnosed glaucoma. The Veteran's claims folder should be made available to the examiner and a complete rationale should be provided for any opinion expressed. The examiner should answer the following questions: a) Is it at least as likely as not (i.e., 50 percent or greater probability) that currently diagnosed glaucoma is related to service, to include the verified in-service chemical exposure (not Agent Orange). b) Is it at least as likely as not (i.e., 50 percent or greater probability) that currently diagnosed glaucoma was caused or aggravated by his service-connected type II diabetes mellitus disability. 3. Schedule the Veteran for a VA skin examination to assist in determining the nature and etiology of any skin disorder. The Veteran's claims folder should be made available to the examiner and a complete rationale should be provided for any opinion expressed. The examiner should then respond to the following: a) Provide a diagnosis for any skin disorder found on examination. b) Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed skin disorder is related to service, to include the verified in-service chemical exposure (not Agent Orange). c) Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed skin disorder was caused or aggravated by his service-connected type II diabetes mellitus disability. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility; rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. "Aggravation" is defined as a permanent increase in the severity of the underlying disability beyond its natural progression. Temporary flare-ups would not be considered aggravation. A rationale should be given for all opinions and conclusions expressed. If an opinion cannot be rendered without resorting to speculation, the examiner should explain why it would be speculative to respond. 4. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the remaining issues in light of all the evidence of record. If any benefit sought on appeal remains denied, the RO should furnish to the Veteran and his representative an appropriate Supplemental Statement of the Case, and should afford them the appropriate time period for response. The Veteran has the right to submit additional evidence and argument on the 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. 2013). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs