Citation Nr: 1516302 Decision Date: 04/15/15 Archive Date: 04/21/15 DOCKET NO. 10-21 627 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a bilateral eye disorder. 3. Entitlement to service connection for a lumbar spine disability. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Becker, Counsel INTRODUCTION The Veteran served on active duty from September 1973 to December 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Among other things, service connection for hepatitis C, for minimal degenerative changes at the L5-S1 disc (claimed as a lower back problem), and for bilateral astigmatism and presbyopia (claimed as blurred vision in eyes) was denied therein. The Veteran appealed each of these determinations. In July 2011, the Veteran testified regarding this matter before the undersigned at a hearing held at the aforementioned RO. The Board recharacterized this matter as one of service connection for hepatitis C, for bilateral eye disorder, and for a lumbar spine disability in January 2012. It then was remanded for additional development. Review of the Veteran's claims file reveals that Board can proceed to make its own determination regarding service connection for hepatitis C at this time but that more additional development is needed prior to the Board making determinations regarding service connection for a bilateral eye disorder and for a lumbar spine disability. The first issue comprising this matter thus is adjudicated herein, while the latter two issues are REMANDED. FINDING OF FACT The Veteran currently has hepatitis C, but there is no nexus between it and his service to include a hepatitis C risk factor therein. CONCLUSION OF LAW The criteria for establishing service connection for hepatitis C have not been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 1113, 1153, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.1, 3.2, 3.102, 3.103, 3.159, 3.301, 3.303, 3.304, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION I. Preliminary Matters VA has a duty of notification regarding a claim for VA benefits. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. Notice must be provided of the evidence necessary to substantiate the benefit(s) sought, that VA will seek to obtain, and that the claimant should submit. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification of how a rating and an effective date will be assigned if service connection is granted also must be provided. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notification must be before initial adjudication or, if it was not required then, there must be subsequent adjudication. Pelegrini, 18 Vet. App. at 112. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). A January 2009 letter contained information on the criteria for establishing service connection generally and for hepatitis C in particular, the evidence required in this regard, and the Veteran's and VA's respective duties for obtaining evidence. It further contained information concerning how ratings and effective dates are assigned for disabilities found to be service-connected. This was prior to initial adjudication via the March 2009 rating decision. In addition to the duty to notify, VA has a duty to assist with respect to a claim for VA benefits. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This includes, as implied from the notification that must be provided, a requirement to aid the claimant in the procurement of relevant records both in government custody and in private custody. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). VA also is required to provide a medical examination and/or obtain a medical opinion when necessary to make a determination. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service treatment records have been procured by VA. The Veteran's representative argues that not all have been obtained because, though crabs are mentioned, treatment for them is not. This argument is unconvincing. Two entries dated in July 1974 reference the Veteran's complaint of crabs, but there is no corresponding diagnosis of crabs. Absent a diagnosis, it is not surprising that treatment is not noted. Otherwise, the service treatment records appear complete. They contain documents concerning the Veteran's entrance into service, treatment for various maladies throughout his service, dental treatment, vaccinations, and his separation from service. A formal finding of unavailability was made with respect to service treatment records in November 2012. Yet, they do not relate to hepatitis C. In addition to service treatment records, VA has procured VA treatment records, Social Security Administration (SSA) records which include many VA treatment records, and identified private treatment records. The Veteran also has supplied some SSA records and private treatment records. Some of all of the aforementioned were obtained in compliance with the Board's January 2012 remand. There may be some outstanding VA and private treatment records (see the remand). However, it is unlikely that any would alter this determination since the information in the obtained records already is duplicative. Per the remand, the Veteran underwent a VA medical examination in March 2012. A September 2012 addendum makes clear that it included review of his claims file. It also included an interview and assessment of him as well as the rendering of a medical opinion. These actions have provided sufficient detail so that the determination made herein is fully informed. As such, no inadequacy is found. Barr v. Nicholson, 21 Vet. App. 303 (2007). None has been alleged by the Veteran or his representative. Significantly, neither the Veteran nor his representative has identified any uncompleted necessary development. No uncompleted necessary development otherwise is apparent. The Board thus finds that no further notice or assistance action is required. In other words, VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio, 16 Vet. App. at 183. There further has been at least substantial compliance with the Board's remand, as is required. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). Adjudication, in sum, may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). Of final note are the duties for conducting hearings. The issues on appeal must be explained, and the submission of outstanding evidence must be suggested. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the beginning of the July 2011 hearing, the undersigned identified hepatitis C as an issue on appeal. Following questions asked by the Veteran's representative on how the Veteran's hepatitis C might be related to service, the undersigned stated that service connection claims involve "relating a current diagnosed disability to service." With respect to outstanding evidence that may concern hepatitis C, SSA records explicitly and VA treatment records implicitly were mentioned. Submission of these records was not suggested by the undersigned, but it is reiterated that they were obtained as a result of the Board's January 2012 remand. II. Service Connection Service connection means that the facts, shown by the evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish direct service connection, there must be a current disability, the incurrence or aggravation of an injury or disease during service, and a nexus between them. Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303. Direct service connection also may be established for any disease diagnosed after separation from service if it was incurred during service. 38 C.F.R. § 3.303(d). For chronic diseases, service connection may be established if there was manifestation during and after service absent an intercurrent cause. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology after service is required if the disease was noted but not chronic or chronicity was questionable during service. Id.; Savage v. Gober, 10 Vet. App. 488 (1997). A rebuttable presumption of service connection exists for chronic diseases when a Veteran served for 90 days or more during a period of war or after December 31, 1946, and the disease manifested, whether or not it was diagnosed, to a compensable degree within the first year after service. 38 U.S.C.A. §§ 1112, 1113, 1153; 38 C.F.R. §§ 3.307, 3.309. Only the most salient evidence must be discussed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Persuasive or unpersuasive evidence must be identified, and reasons must be provided for rejecting favorable evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Wilson v. Derwinski, 2 Vet. App. 614 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay evidence may be discounted in light of its inherent characteristics and relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence, the claimant must be afforded the benefit of the doubt. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. A current disability must be present near or at the time a claim is filed or at any time during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). Here, the Veteran filed an informal claim for a number of issues to include hepatitis C in December 2008. He filed a formal claim to include hepatitis C as an issue in January 2009. All indications are that he has had hepatitis C as a current disability since a few years prior to filing these claims. At the March 2012 VA medical examination, the Veteran recalled first being informed that he had hepatitis C after giving blood in 2004 or 2005. This corresponds with VA treatment records, which note that diagnosis was made in May 2004. The diagnosis was confirmed at the aforementioned examination. Hepatitis C has not been designated by VA as a chronic disease. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a). Service connection accordingly cannot be presumed notwithstanding that the Veteran served for over a year, and thus well over 90 days, during a period of war after December 31, 1946, referred to for VA purposes as the Vietnam era. 38 U.S.C.A. § 101(29); 38 C.F.R. § 3.2(f). Service connection also cannot be granted based on chronicity or continuity of symptomatology absent a chronic disease. However, the onset of the disability as well as the onset and persistence of relevant symptoms still must be taken into account in relation to direct service connection. Except for any defects noted, a Veteran is presumed to be in sound condition upon entrance into service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Noted means only defects that are identified upon examination. 38 C.F.R. § 3.304(b). The Veteran denied jaundice or hepatitis and stomach, liver, or intestinal trouble at his September 1973 entrance examination. More importantly, no notation of any abnormality in this regard was made then. The Veteran therefore is presumed to have been sound. The applicable inquiry thus is whether or not he incurred as opposed to aggravated a relevant injury or disease during service. Service treatment records do not reflect complaints or diagnosis of hepatitis C or any other liver problem. However, an October 1974 entry indicates that the Veteran complained of intermittent stomach pains for approximately three months and of vomiting. The Veteran's representative argued in a March 2015 brief that this was the first sign of hepatitis C. Attached thereto is a printout from the Centers for Disease Control (CDC) website identifying abdominal pain and vomiting as symptoms of acute (soon after contraction) hepatitis C. Though not mentioned by the Veteran's representative, an April 1974 entry indicates that the Veteran complained of nausea without vomiting. He had a fever. Both are identified by the CDC as symptoms of acute hepatitis C. Yet the CDC also points out that most individuals, or 70 to 80 percent, are asymptomatic. The Veteran did not complain of relevant symptoms between April 1974 and October 1974 or between October 1974 and his December 1974 separation. Though there is no record of his complaints at the time of his December 1974 separation examination, which found no abnormalities related to hepatitis C, it thus may be that these symptoms resolved. Indeed, the Veteran has not recounted persistent symptoms with an onset during service. He rather argues that his hepatitis C remained dormant for quite some time prior to first diagnosis. Hepatitis C indeed often first is detected many years after transmission. VA Training Letter 98-110 (November 30, 1998). It finally is of import that flu syndrome was diagnosed in April 1974 and gastritis was diagnosed in October 1974 to account for the Veteran's symptoms. No reference was made to hepatitis C, and there is nothing else to suggest that hepatitis C was considered as a potential cause of these symptoms on either occasion. In sum, acute hepatitis C or the onset of hepatitis C during service has not been established. The Veteran contends, however, that he had a qualifying risk factor for hepatitis C during service. His representative argues that he may have had another qualifying risk factor during service. Another qualifying risk factor further may have existed. Hepatitis C primarily is transmitted by contact with blood and blood products, with the highest prevalence correlated to repeated and direct percutaneous (through the skin) exposure. VA Fast Letter 04-13 (June 29, 2004). The large majority of those with hepatitis C thus contract it by known modes of transmission such as intravenous/injection drug use with shared instruments and transfusion before screening of the blood supply began in 1992. Id. Reuse of needles for tattoos, piercings, and acupuncture also is a potential mode of transmission. Id. Other potential risk factors include intranasal cocaine use involving shared instruments, high risk sexual activity, sharing a toothbrush or razor, and accidental exposure to blood. VA Training Letter 01-02 (April 17, 2001); VA Training Letter 98-110. The specifically contends that he could have hepatitis C as a result of being promiscuous during service. With no indication that he has any medical background, the Veteran is a lay person. A lay person is competent when relating that which is personally experienced or witnessed. Layno v. Brown, 6. Vet. App. 465 (1994). The Veteran therefore is competent to recount the aforementioned. He also is credible to recount the aforementioned. Factors for consideration in this regard include interest, bias, inconsistency, implausibility, bad character, malingering, desire for monetary gain, and witnessed demeanor. Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). The Veteran is interested in recounting the aforementioned in that doing so may lead to a grant of service connection would in turn make it possible for him to receive compensation benefits. He thus may be motivated by a desire for monetary gain. Nevertheless, there is no indication of bad character or malingering. The Veteran's demeanor at the July 2011 hearing conveyed his truthfulness. He indeed was forthright about having multiple sexual partners. That he had multiple sexual partners during service is entirely plausible. During the pendency of his appeal, the Veteran has never wavered in recounting his promiscuity during service. He has been consistent, in other words. Service treatment records finally are consistent with his recount, at least to the extent of engaging in sexual activity. They also show that at least some of this activity was high risk. An October 1973 entry shows that he complained of a rash. The diagnosis made was venereal wart. It additionally is reiterated that the Veteran twice complained of crabs, though no treatment was mentioned, in July 1974. The Veteran's representative argues that it is possible the Veteran contracted hepatitis C during service via a contaminated object. However, the only support for this is reference to a two inch scar on his stomach made at his December 1974 separation examination. It is presumed that this scar arose during service since there is no notation of it at the September 1973 entrance examination. Yet, there are no entries concerning stomach surgery. A lack of notation of any event where such would be expected, like in the case of a significant medical procedure like surgery, suggests the event did not occur. Buczynski v. Shinseki, 24 Vet. App. 221 (2011). Further, there are no entries concerning a stomach injury. It finally is of great import that the Veteran has not recounted stomach surgery or a stomach injury during service. He indeed has not even mentioned his scar. Lacking any specifics about it, his coming into contact with a contaminated object cannot be established. In the March 2015 brief, the Veteran's representative noted that the military started drug testing in 1974. Attached thereto was an Army regulation regarding the drug abuse testing program with an effective date of January 1, 1974. The Veteran was in the Navy, not the Army. However, the aforementioned effective date is accepted for the sake of argument. The Veteran's representative next noted in the brief that the Veteran never had a positive drug test during service and thus never was referred for rehabilitation or other drug treatment. Service treatment records lack any entries in this regard, but this does not establish that the Veteran did not use drugs during service. SSA records indeed include a January 2007 examination, during which he recounted drug use when he was in the Navy. At the March 2012 VA examination, he recounted intranasal cocaine use and heroin use in service. The Veteran is competent to make this recount for the same reason already discussed. He also is credible to make it, for many of the same reasons already discussed. Regarding inconsistency, that service treatment records do not support the recount is of no consequence. A lay person's recount cannot be discounted merely because there is no contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). That the Veteran never was drug tested even though he used drugs during service indeed is quite possible, from which it follows that rehabilitation or other drug treatment would not be mentioned. Yet service connection for hepatitis C, even if as a result of drug use during service, cannot be granted. A disability incurred or aggravated during service as a result of the Veteran's own willful misconduct is not service-connectable. 38 C.F.R. § 3.301(c)(2). Willful misconduct is an act involving conscious, deliberate, or intentional wrongdoing with knowledge of or wanton and reckless disregard for the probable consequences. 38 C.F.R. § 3.1(n). Isolated and infrequent drug use is not willful misconduct, but progressive and frequent use to the point of addition is willful misconduct. 38 C.F.R. § 3.301(c)(3). The frequency of the Veteran's drug use during service is unknown. It accordingly cannot be determine whether or not it constituted willful misconduct. Even if it did not constitute willful misconduct, a disability resulting from an injury or disease incurred or aggravated during service as a result of drugs use is not service-connectable. 38 C.F.R. § 3.301(d). In sum, the only established hepatitis C risk factor during service is high risk sexual activity. Hepatitis C risk factors following service are also important. There are indications that the Veteran continued to engage in high risk sexual activity after his separation. An October 2000 private treatment record documents the Veteran's complaint of a sexually transmitted disease. The outcome is unclear, as the record is illegible. A May 2010 private treatment record references unprotected sex. A November 2005 VA treatment record also mentions a history of unprotected sexual activity. August 2009 and October 2010 VA treatment records reveal the Veteran's complaint of a sore or blister on his penis. The diagnosis was herpes simplex virus and venereal disease exposure. Additionally, all indications are that the Veteran continued to use drugs following service. He reported alcohol, marijuana, cocaine, and crack cocaine use at the January 2007 examination found in SSA records. At the March 2012 VA medical examination, he denied alcohol use but reported intranasal cocaine use. VA treatment records are rife with his reports of drug use, to include cocaine, crack cocaine, and heroin, since service. These records also are rife with his reports of smoking, snorting, and intravenous delivery methods. He lastly reported in VA treatment records dated in November 2005 and June 2009 to some sharing of drug equipment including straws. For essentially the same reasons as above, the Veteran is competent and credible in making these reports. Of import in this regard once again is inconsistency or in this instance the lack thereof. VA treatment records indeed contain positive drug tests for cocaine and opiates. It is reiterated that the Veteran asserts only that his high risk sexual activity during service is possibly the cause of his hepatitis C. He does not assert that it is the cause. This latter assertion, in any event, would not be competent coming from him. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A lay person sometimes can confirm nexus. Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); Davidson, 581 F.3d at 1313; Jandreau, 492 F.3d at 1372. Whether there exists a nexus here falls outside the province of a lay person, however. It is a medical question. Indeed, it is reiterated that hepatitis C often first is detected many years after transmission. The Veteran further has multiple risk factors. Only those with a medical background are competent to answer medical questions. Jones v. West, 12 Vet. App. 460 (1999). There are no private opinions concerning nexus. One VA opinion, rendered at the March 2012 VA medical examination, exists. In considering a medical opinion, the qualifications and expertise of the individual rendering the opinion, the scope of the assessment, whether or not pertinent evidence was reviewed, the accuracy of the factual premises underlying the opinion, the rationale provided for it, and degree of certainty in it are factors for consideration. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Ardison v. Brown, 6 Vet. App. 405 (1994); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The individual who rendered the opinion identified himself as a physician specializing in hepatology/gastroenterology. It is reiterated that the claims file was reviewed and that the Veteran was interviewed and assessed. None of these actions were deficient. Consideration was given to the Veteran's recount of having yellow eyes during service. Jaundice (yellow color in the skin or eyes) is identified by the CDC as symptoms of acute hepatitis C. However, it was noted that service treatment records did not indicate jaundice or hyperbilirubinemia. Some indication would be expected, especially since the December 1974 separation examination included a general evaluation of the Veteran's eyes. Buczynski, 24 Vet. App. at 221. Though his recount is competent, it thus is not credible. Hepatitis C risk factors both during and following service also were addressed. In addition to his drug use in service and after his separation as already discussed, the Veteran denied exposure to blood or blood products through combat as well as occupation, blood transfusion, body piercing, and dialysis at any time. He also denied knowingly having a sexual encounter with an individual infected with hepatitis C. In rendering the opinion, unequivocal language was used. This opinion was that it is not at least as likely as not that the Veteran's hepatitis C had its onset during service or is otherwise related to his service. A rationale was provided in support of this opinion. It was noted that even intranasal drug use without intravenous drug use is a risk factor for contracting hepatitis C. A medical journal article was cited in this regard. This source notably is in agreement with the aforementioned VA Fast Letter and VA Training Letters. Reference then was made to the duration of risk factors during service and the duration of risk factors following service. Implied from this reference is that the Veteran's exposure to hepatitis C was much more substantial in the many years following service than during his short time in service. An inaccurate premise is evident in the rationale. It is clear that only intranasal drug use was considered, since that is all that was reported then, even though the Veteran otherwise has reported intravenous use as well. Reliance on this inaccurate premise, which is a fact not that his report has been found competent and credible, is of no consequence. The aforementioned VA Fast Letter and VA Training Letters make clear that intravenous drug use carries more risk for becoming infected with hepatitis C than does intranasal drug use. Reliance was placed on a lesser risk factor in rendering a negative opinion, in other words. The opinion therefore still would be negative given the higher risk factor. In any event, that the Veteran's hepatitis C was attributed to his drug use over his high risk sexual activity whether during service or following service is implicit. Unfortunately, no medical journal article or other source was cited for high risk sexual activity being a lower risk factor for hepatitis C than intranasal (and thus also intravenous) drug use. Yet high risk sexual activity is well-recognized as a low risk factor. An August 2004 VA treatment record conveys that the Veteran was educated regarding hepatitis C to include that sexual activity carries a low risk of transmission. Population studies indeed have confirmed that the rate of sexual transmission of hepatitis C is well below the rates for HIV/AIDS or hepatitis B. VA Fast Letter 04-13. A study of five groups of monogamous couples in which one partner was infected with hepatitis C while the other partner was not found that less than five percent of uninfected partners became infected. Id. The risk factor which led to the Veteran's hepatitis C, in sum, may never be known because there are two main risk factors. Yet, it is far more likely that his drug use both during and after service was the cause over his high risk sexual activity during service. Accordingly, the criteria for establishing service connection for hepatitis C have not been met. This determination was made based on the preponderance of the evidence. Evidence against service connection, chiefly the opinion rendered at the March 2012 VA medical examination and well-recognized medical principles, is particularly persuasive in this regard. Absent an approximate balance between the evidence against service connection and the evidence for service connection, there is no benefit of the doubt to afford to the Veteran. Service connection for hepatitis C is denied. ORDER Service connection for hepatitis C is denied. REMAND Although the delay entailed by a second remand is regrettable, Board adjudication of the Veteran's entitlement to service connection for a bilateral eye disorder and for a lumbar spine disability cannot occur yet. Undertaking additional development prior to this adjudication is the only way to ensure that he is afforded every possible consideration. He must be afforded such consideration. That VA has a duty to assist him in substantiating his claim indeed is reiterated. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has a duty to assist the Veteran in gathering evidence that may show he is entitled to the benefits sought, in other words. The duty to assist includes making as many requests as necessary to obtain treatment records in government custody, unless it is concluded they do not exist or further requests would be futile. 38 U.S.C.A. § 5103A(b)(3); 38 C.F.R. § 3.159(c)(2). When the existence of private treatment records is discovered, the claimant must be asked to submit them or provide enough information to identify and locate them along with an authorization for their release. 38 C.F.R. §§ 3.159(c)(1), (e)(2). If information and authorization is provided, an initial request and if necessary one or more follow-up requests must be made. 38 C.F.R. § 3.159(c)(1). The claimant shall be notified if any requested records cannot be or are not obtained. 38 U.S.C.A. § 5103A(b)(2); 38 C.F.R. § 3.159(e)(1). Here, VA treatment records dated into January 2012 are available. Some concern ongoing care for the Veteran's eyes, and some concern ongoing care for his back. Others dated from January 2012 to present therefore likely exist. A request or requests for them must be made. Indeed, VA has constructive notice of all its own treatment records. Bell v. Derwinski, 2 Vet. App. 611 (1992). Private treatment records also are available and concern the Veteran's eyes several ongoing care episodes for his back. It is possible that others exist particularly regarding his back. The Veteran must be asked to submit or provide enough information to identify and locate any along with authorization for their release. An initial request with follow-up requests as necessary must be made if he does the latter. Notice to him and his representative finally must be made if the aforementioned is unsuccessful. If a VA medical examination and/or a VA medical opinion has been provided, the duty to assist requires that it be adequate. Barr, 21 Vet. App. at 303; Hayes v. Brown, 9 Vet. App. 67 (1996). Adequacy occurs when the Board can perform an informed adjudication. Barr, 21 Vet. App. at 303. The Veteran's entire history accordingly must be taken into account. Stefl, 21 Vet. App. at 120; Ardison, 6 Vet. App. at 405. Any disability present must be described in sufficient detail at the examination. Id. All factual premises underlying the opinion must be accurate. Reonal, 5 Vet. App. at 458. A rationale for the opinion further must be clearly and fully articulated. Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 120. The Veteran underwent a VA medical examination for his eyes, as directed by the Board's January 2012 remand, in March 2012. A January 2013 addendum included the directed VA medical opinion concerning his eyes. Both the examination and opinion are inadequate. Cataracts were diagnosed and concluded to be unrelated to the Veteran's service because they have a multifactorial etiology, are slowly progressive so pinpointing onset is impossible, and age appropriate. No further explanation was provided. Dry eye syndrome and hypertensive retinopathy were found to be old diagnoses, but no etiological opinion was rendered for them. To the contrary, the previous remand discussed VA treatment records documenting the first diagnosis around at the outset of the Veteran's claim and potentially the second. An opinion accordingly is required for the first and maybe the second, each even if they no longer are appropriate diagnoses. Romanowsky, 26 Vet. App. at 289; McClain, 21 Vet. App. at 319. The same is true of arcus, which was not even mentioned and for which there thus is no opinion. Also in March 2012, the Veteran underwent a VA medical examination complete with VA medical opinion for his back. The examination is inadequate, as is the opinion. It was indicated that he has never had a thoracolumbar spine disability. This is despite later references to arthritis and degenerative changes. It also is despite numerous VA and private treatment records as well as SSA records documenting back problems to include degenerative changes. Such changes were concluded to be unrelated to the Veteran's service but rather due to age. No explanation was provided as to how they are attributable to age. Regarding service, it was explained only that the Veteran was seen for two low back strains. Service treatment records pertinent to his back do not contain a diagnosis of strain, however. It thus is unclear how this finding was made. The aforementioned VA medical examinations, in sum, do not describe sufficiently the disability present. Each of the aforementioned VA medical opinions is too terse to be useful. This is despite the Board's request in the previous remand for a clear rationale, which includes a discussion of the facts and medial principles involved. In other words, there has not been the required substantial compliance with the Board's remand directives. Stegall, 11 Vet. App. at 268. Finally, it does not appear that the Veteran's entire history even as of the time was taken into account. There may be more history to take into account now, should more VA and/or private treatment records be obtained as a result of this remand. Arrangements must be made for the Veteran to undergo another VA medical examination complete with medical opinion concerning his eyes and concerning his back for these reasons. Given the above, a REMAND is directed for the following: 1. Make as many requests as necessary to obtain all VA treatment records regarding the Veteran, but particularly those with respect to care concerning his eyes and back, dated from January 2012 to the present. Associate all records received with the paper or electronic claims file. Notify the Veteran and his representative pursuant to established procedure of any lack of success regarding the aforementioned. 2. Ask the Veteran to either submit any private treatment records concerning care for his eyes or back or provide enough information to identify and locate any along with an authorization for their release to VA. If he does the latter, make an initial request with follow-up as necessary. Associate all records received with the paper or electronic claims file. Notify the Veteran and his representative pursuant to established procedure of any lack of success regarding the aforementioned. 3. After completion of the above, arrange for the Veteran to undergo a VA medical examination regarding his eyes. The examiner shall review the claims file, documenting such in a report to be placed therein. The examiner also shall document in the report an interview with the Veteran regarding his history, symptoms, and their impact on his work and daily life. All necessary tests next shall be performed, the results of which shall be set forth in the report. A diagnosis or diagnoses of all eye disorders present since around December 2008, regardless of whether or not they are still present, then shall be rendered. Cataracts, dry eye syndrome, hypertensive retinopathy, and arcus must be considered in this regard. Finally, the examiner shall opine in the report as to whether it is at least as likely as not (a 50 percent or greater probability) that each diagnosis is related to the Veteran's service. A clear and full rationale also (explanation) must be provided for each opinion. This requires that medical principles be discussed as they relate to the medical and lay (non-medical) evidence. If an opinion cannot be reached without speculation, the examiner shall discuss why. A copy of, or at least a citation to, any medical literature referenced in the report finally shall be provided by the examiner. The examiner is advised that the Board previously found the Veteran's recount of experiencing continuous symptoms, such as pain, redness, a burning sensation, and blurry vision since service to be credible. The examiner also is advised that he attributes these symptoms to his exposure to various solvents and toxic substances while performing his duties maintaining the ship during service. 4. Also after completion of the development requested in paragraphs one and two above, arrange for the Veteran to undergo a VA medical examination regarding his lumbar spine. The examiner shall review the claims file, documenting such in a report to be placed therein. The examiner also shall document in the report an interview with the Veteran regarding his history, symptoms, and their impact on his work and daily life. All necessary tests next shall be performed, the results of which shall be set forth in the report. A diagnosis or diagnoses of all lumbar spine disabilities present then shall be rendered. Finally, the examiner shall opine in the report as to whether it is at least as likely as not (a 50 percent or greater probability) that each diagnosis is related to the Veteran's service. A clear and full rationale also (explanation) must be provided for each opinion. This requires that medical principles be discussed as they relate to the medical and lay (non-medical) evidence. If an opinion cannot be reached without speculation, the examiner shall discuss why. A copy of, or at least a citation to, any medical literature referenced in the report finally shall be provided by the examiner. The examiner is advised that service treatment records contain several entries regarding the Veteran's back. The examiner also is advised that the Board previously found that he did not have a preexisting back disability prior to service. Further, the Board previously found that the Veteran's recount of experiencing continuous symptoms, primarily pain with some numbness, since service to be credible. The examiner next is advised that the Veteran believes that his back symptoms began during service and that he attributes his back symptoms to his exposure to various solvents and toxic substances while performing his duties maintaining the ship during service. Finally, the examiner is advised that the Veteran involved in a motor vehicle accident in 2000 and another which injured his back in 2003. 5. Finally, readjudicate the issues of entitlement to service connection for a bilateral eye disorder and for a lumbar spine disability. Issue a rating decision if either determination is favorable. Issue a supplemental statement of the case (SSOC) if either determination is unfavorable. Provide a copy of the rating decision and/or SSOC to the Veteran and his representative, and place a copy in the claims file. Allow them the requisite time period to respond to a SSOC before processing for return to the Board. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring that the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Wood v. Derwinski, 1 Vet. App. 190 (1991). His failure to help procure treatment records, for example, may impact the determination made. His failure to report for a VA medical examination may have the same impact. 38 C.F.R. § 3.655 (2014). The Veteran also is advised that he has the right to submit additional evidence and argument concerning the issue(s) of this matter subject to this remand. Kutscherousky v. West, 12 Vet. App. 369 (1999). They must be afforded prompt treatment. The law indeed requires that all remands by the Board or the United States Court of Appeals for Veterans Claims be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112. ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs