Citation Nr: 0511669 Decision Date: 04/25/05 Archive Date: 05/03/05 DOCKET NO. 98-08 029 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for a lung disorder. 2. Entitlement to service connection for eosinophilia- myalgia syndrome with gastric residuals, claimed as secondary to service-connected eosinophilia. 3. Entitlement to service connection for dry eye syndrome, claimed as secondary to service-connected eosinophilia. 4. Entitlement to an increased (compensable) evaluation for eosinophilia. REPRESENTATION Appellant represented by: Sean Kendall, Attorney-at-Law WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The veteran had active service from January 1953 to December 1954. In December 1964, the Board of Veterans Appeals (Board) denied service connection for a lung disorder on a direct and secondary basis. The veteran and his representative were provided a copy of this decision. In March 2000, the Board promulgated a decision which denied the veteran's request to reopen the claim for a lung disorder, and denied service connection and an increased rating for the remaining three issues shown on the title page of this decision. The veteran timely appealed the Board's decision to the United States Court of Appeals for Veterans Claims (hereinafter, "the Court"). In April 2001, the Court granted an unopposed motion to vacate and remand the March 2000 Board decision. In April 2002, the Board reopened the claim of service connection for a lung disorder and undertook additional development, including referral of the claim to a VA Medical Center for an expert medical advisory opinion. In March 2004, the Board remanded the appeal to the RO for additional development, in light of the holding in Disabled Am Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), which invalidated (inter alia) 38 C.F.R. § 19.9(a)(2), a provision giving the Board authority to undertake case development before issuing an appellate decision. FINDINGS OF FACT 1. All evidence necessary for adjudication of this claim have been obtained by VA. 2. A lung disorder was not present in service and was first shown years after separation from service; it is not causally or etiologically related to a service-connected disability. 3. Eosinophilia-myalgia syndrome with gastric residuals is not causally or etiologically related to a service-connected disability. 4. Dry eye syndrome is not causally or etiologically related to a service-connected disability.. 5. The veteran is not shown to have any signs, symptoms, or diagnostic evidence of eosinophilia, or any residuals thereof, at any time during the appeal period. CONCLUSIONS OF LAW 1. A lung due to disease or injury was not incurred in or aggravated by service, and is not proximately due to or the result of service-connected eosinophilia.. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2004). 2. Eosinophilia-myalgia syndrome with gastric residuals was not incurred in or aggravated by service, and is not proximately due to or the result of service-connected eosinophilia. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.310 (2004). 3. Dry eye syndrome was not incurred in or aggravated by service, and s not proximately due to or the result of service-connected eosinophilia. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.310 (2004). 4. The criteria for a compensable evaluation for eosinophilia have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.20, 4.31, 4.117, Part 4, Diagnostic Code 7799 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that there has been a significant change in the law during the pendency of this appeal, with enactment of the Veterans Claims Assistance Act of 2000 (VCAA), now codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002). This law redefines the obligations of VA with respect to the duty to assist, including to obtain medical opinion where necessary, and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. In Pelegrini v. Principi, 18 Vet. App. 112, (2004), referred to as Pelegrini II, although the United States Court of Appeals for Veterans Claims (hereinafter, "the Court") noted that the statute and the regulation provide for pre- initial-AOJ adjudication notice, the Court also specifically recognized that, where, as in the case currently before the Board, that notice was not mandated at the time of the initial AOJ decision, the AOJ did not err in not providing such notice specifically complying with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 because an initial AOJ adjudication had already occurred. The Board concludes that information and discussions as contained in the April 1998 and July 1998 rating decisions, the May 1998 statement of the case, the November 1998 and January 2005 supplemental statements of the case (SSOC), the April 2002 Board decision and the March 2004 Board remand, and in a letter sent to the veteran in March 2004 have provided him with sufficient information regarding the applicable regulations. Additionally, these documents notified him why this evidence was insufficient to award the benefits sought. The veteran also testified at a hearing at the RO in August 1998. Thus, the veteran has been provided notice of what VA was doing to develop the claim, notice of what he could do to help his claim, and notice of how his claim was still deficient. Because no additional evidence has been identified by the veteran as being available but absent from the record, the Board finds that any failure on the part of VA to further notify the veteran what evidence would be secured by VA and what evidence would be secured by the veteran is harmless. Cf. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board finds that the record has been fully developed, and that it is difficult to discern what further guidance VA could have provided to the veteran regarding what additional evidence he should submit to substantiate his claims. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). There is no indication that there is additional evidence to obtain; there is no additional notice that should be provided; and there has been a complete review of all the evidence without prejudice to the veteran. As such, there is no indication that there is any prejudice to the veteran by the order of the events in this case. See Bernard v. Brown, 4 Vet. App. 384 (1993). Any error in the sequence of events is not shown to have any effect on the case or to cause injury to the veteran. The Board concludes that any such error is harmless, and does not prohibit review of this matter on the merits. See ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998); Miles v. Mississippi Queen, 753 F.2d 1349, 1352 (5th Cir. 1985). Factual Background The service medical records show that the veteran was hospitalized for eosinophilia of unknown cause in August 1954. He complained of increasing bilateral flank pain of one month's duration. On admission, white blood count was 17,000 and eosinophils were 17 percent. Routine urinalysis, muscle biopsy, and three stool studies for parasites were negative. Intravenous and retrograde pyelograms showed an anatomic abnormality in the right renal pelvis without evidence of obstruction. The significance of the abnormality was unknown. Cardiolipin was negative and a throat culture showed no significant organisms. Eosinophilia on the second day was 14 percent. The veteran experience very little back pain during his hospital stay and was released on the 13th day. The final diagnoses include eosinophilia of undetermined cause. Subsequent laboratory studies in September 1954 showed eosinophils of 7 percent. Service medical records are silent for complaints of dry eyes, gastric problems, myalgia, or lung problems. His separation examination in December 1954 showed no blood abnormalities, dry eyes, gastric problems, myalgia, or lung problems. A claim of service connection for a blood and kidney disorder was received in January 1955. When examined by VA in February 1955, the veteran denied any gastrointestinal problems. Intravenous pyelograms showed a distortion of the right kidney pelvis, the cause of which was not evident, but possibly a congenital anomaly. Laboratory studies showed eosinophils of 10 percent. The diagnoses included eosinophilia, pyuria, and negative retrograde urograms. The veteran was hospitalized at a VA medical facility with a diagnosis of spontaneous right pneumothorax in October 1959. He was initially treated by a family physician in late September for severe right anterior chest pain radiating to the posterior scapular area. He denied any chills, fever, or significant cough, but noted some night sweats. Pleurisy was diagnosed, and treatment was a shot of penicillin and tetracycline. His symptoms improved somewhat, and he had a slight productive cough of white mucoid sputum streaked with black, but no hemoptysis. Another shot of penicillin provided no relief and he was referred to a radiologist who diagnosed a collapsed lung. He was then referred to the VA for additional treatment in early October 1959. When admitted to the VA hospital in October 1959, the veteran reported that he smoked 11/2 packs of cigarettes a day. Laboratory studies showed eosinophils of 6 percent with a total count of 462 per cubic millimeters. Except of the collapsed lung, all remaining diagnostic studies and clinical findings were within normal limits. The veteran underwent a wedge resection of a cyst on the mediastinal surface of the middle right lobe without complication. The veteran continued to improve and was discharged after one month. The final diagnoses included spontaneous right pneumothorax and eosinophilia, cause undetermined. When examined by VA in October 1961, laboratory studies all studies were within normal limits. The veteran was admitted to a VA medical facility in March 1962, for evaluation of multiple symptoms, including weakness and shortness of breath with minimal exertion. He reported a productive cough in the morning with no wheezing or cyanosis. His main complaint was chronic low back pain precipitated by minimal exertion. Laboratory studies showed eosinophils of 2 percent. A chest x-ray study revealed a density, felt to be a pleural nodule, at the level of the lower margin of the sixth right rib, which was not present on previous films in 1959. The examiner commented that the veteran no longer had eosinophilia and opined that the spontaneous pneumothorax, back pain, or any of the veteran's other complaints were not related to eosinophilia, which he no longer had. The claims file was referred to a VA radiologist in March and April 1964, for an opinion as to the possible relationship between the veteran's eosinophilia in service and the subsequent cyst of the right lung. The radiologist provided a detailed description of the numerous chest x-rays studies taken in service, and in 1959 and 1962, and concluded that the ill-defined shadow at the right 6th and 7th posterior interspace most likely represented an exostosis or proliferate change probably from the previous surgical intervention and was of no clinical significance. In May 1964, the claims file was reviewed by a VA physician for an opinion as to the possible relationship between the veteran's eosinophilia in service and the cyst in the right lung in 1959. He noted that eosinophilia was a symptom rather than a disease, and that it was usually caused by parasitic disease, diseases of the skin, allergies such as asthma, angioneurotic edema, serum sickness, liver therapy in pernicious anemia, and Hodgkin's disease. However, studies for parasitic and renal disease in service and by VA in 1955 were negative. The physician pointed out that the operative report in 1959 indicated that the cyst in the middle segment of the right middle lobe was described as congenital. The pathological report indicated that the tissue was chronic inflammation, pulmonary fibrosis, severe, and pulmonary emphysema. The physician concluded hat the cause of the veteran's eosinophilia in service was undetermined; that the eosinophilia no longer existed; and that there was no relationship between eosinophilia and spontaneous pneumothorax. He opined that it was much more likely that the spontaneous pneumothorax was related to and the result of a congenital cyst of the right lung. A memorandum from the Director of the VA Radiology Service, dated in November 1964, indicated that the claims file and chest x-ray studies had been reviewed. The physician noted that there was no evidence of pulmonary pathology in any of the service medical records or chest x-ray studies. The cyst removed in 1959 was a pleural cyst or sub-pleural pneumatocele, which ruptured and caused the spontaneous pneumothorax. He noted that pulmonary cysts of this type did not cause eosinophilia. The physician opined that there was no causal relationship between the pulmonary cyst and eosinophilia unless the cyst was due to parasitic disease or some allergic disease such as asthma. However, in this case, there was no evidence of any parasitic or allergic disease in service. On VA examination for insurance purposes in September 1971, the examiner indicated that he reviewed the claims file and provided a detailed medical history. Blood studies showed white blood count of 8,600; a result for eosinophils was not indicated. Private medical records received from Suburban General Hospital in April 1998, showed that the veteran was hospitalized in June 1991 for fever, chills, dysuria, and voiding small amounts as well as urinary frequency several days earlier. The veteran reported that he used to be a heavy smoker, but now only smoked two to three cigarettes a day. Laboratory studies showed eosinophils of 2 percent; normal range was indicated between 0 and 5 percent. Blood and urine cultures showed no growths in five days. A CT scan of the thorax revealed evidence of emphysematous changes involving the right upper lobe. A chest x-ray study showed an ill-defined patchy infiltration involving the posterior segment of the right lobe due to pneumonic infiltrate. The examiner noted a history of thoracotomy many years ago for what sounded like a pneumothorax and spontaneous rupture of a blep. The veteran testified at a personal hearing at the RO in November 1998, that he was treated for fever, chills, frequency, and back pain during service, and that he has been sick ever since. (T p.2) VA medical records associated with the claims file in November 1998 show that the veteran was treated for various maladies on numerous occasions from 1962 to 1998. The first complaints of heartburn type symptoms were noted in October 1982. Heartburn, hiatal hernia, and gastroesophageal reflux (GER) were noted in April 1992. A history of chronic obstructive pulmonary disease (COPD), hiatal hernia, and asthma were noted in November 1992. An undated note in what appears to be 1993, noted complaints of watery eyes and other symptoms consistent with rhinorrhea. Restrictive airway disease was noted in December 1992. The veteran was seen at the eye clinic on several occasions from August 1994 to April 1998, primarily for suspected glaucoma and possible early cataracts. There was no mention of dry eye or any other significant eye disorder other than refractive error. Upper gastrointestinal studies in May 1995 showed no hiatal hernia or GER. However, there was a suspected small ulcer crater in the duodenal bulb. The records also show treatment on several occasions for side affects from hypertensive medications, primarily lightheadedness and dizziness. In October 1996, the veteran denied any shortness of breath, visual changes, weakness, paresthesias, or previous similar history. A progress note in November 1998 was also negative for any symptoms other than dizziness. The veteran's represented submitted a number of letters, received at various times during the course of the appeal, from several private physicians, including S. G. Basheda, M.D., M. Ramsay, M.D., and C. N. Bash, M.D. In August 2000, Dr. Basheda indicated that he was treating the veteran for a respiratory disorder at a private hospital. He stated that the veteran apparently developed a respiratory illness associated with eosinophilia during service, which he believed represented asthma. In December 2001, he stated that asthma can be associated with eosinophilia. Although asthma is termed a reversible obstructive lung disease, certain people develop persistent obstruction that can mimic COPD from smoking cigarettes. Therefore, he could not discount the possibility that the veteran's condition being persistent asthma and eosinophilia that occurred in service. A letter from Dr. M. Ramsay in November 2001 indicated that a chest x-ray study showed the lungs were emphysematous, with pulmonary hyperinflation, minimal pulmonary scarring, and no well-defined pneumonic type consolidations. A pleural effusion was not manifested. The impression included COPD. He opined that a superimposed active disease process was not seen. On VA pulmonology examination in June 2002, the examiner indicated that the claims file was reviewed and included a description of the veteran's medical history. The examiner noted that at the time of the veteran's spontaneous pneumothorax in 1959, the operative report indicated that the lung was leaking from a congenital cyst. The surgeon did not describe any other bullae. Therefore, it was likely that the cause of the spontaneous pneumothorax was bullous lung disease, which has been radiographically shown many times since then. He noted that in 1962, the veteran had a chronic productive cough, but no evidence of bronchospasm on examination. PFTs reportedly showed vital capacity of 107 percent, but there were no reported findings for FEV1, which could be useful in determining the presence of obstructive airway disease. On examination, the veteran reported that he contracted some type of febrile illness in service and was hospitalized and told that he had eosinophilia. He said he continued to have a problem but that he was discharged from the service and told that he would be contacted by the VA. He had a spontaneous pneumothorax in 1959, and has had intermittent chest tightness and shortness of breath ever since. The veteran reported that he smoked less than a pack of cigarettes a day for nine years from age 18 until the spontaneous pneumothorax in 1959, at which time he quit. The diagnoses included COPD - a combination of reactive airway disease with asthma and bullous emphysema; gastroesophageal reflux (GER) disease, and history of eosinophilia in service. The examiner opined that it was as likely as not that the veteran's current lung pathology, asthma and COPD, were causally related to his service-connected eosinophilia. He commented that it was possible that the veteran had atopic disease and allergies, which was the a cause of his asthma, and that it was not uncommon that such patients manifest eosinophilia at various stages of their illness. He could not offer a definitive opinion as to whether the veteran's current lung disorder had its onset in service, but noted that there was no evidence of asthma in service or until at least 20 years after service. He indicated that the current lung pathology of emphysema could have been present in service if the veteran was alpha-1 antitrypsin deficient. After subsequent testing revealed the veteran was not alpha-1 deficient, he said that it unlikely that his bullous lung disease was due to a deficiency of this inhibitor or that it was present in service. He then stated that bullous lung disease was essentially a congenital disease that often leads to spontaneous pneumothorax in young males, therefore, it was as likely as not that the lung pathology was present during service. In April 2003, the claims file was referred to a VA pulmonologist for review and an opinion regarding the etiology and, if possible, relationship between the current disabilities for which the veteran seeks service connection and his symptoms of eosinophilia in service. In May 2003, the VA physician indicated that he reviewed the claim file and provided a detailed description of the veteran's medical history. He noted that when the veteran was seen for fatigue, urinary frequency, and flank pain in service, an eosinophilia of 17 percent was unexpectedly discovered. The veteran had eosinophilia of 10 percent on VA examination in February 1955, but no laboratory studies were done for four years after that. The next study was in October 1959 and showed eosinophilia of 6 percent with absolute count of 462. In October 1961, eosinophilia was normal, as were all subsequent laboratory studies, including up to the present time. He also noted that there were no respiratory complaints or pulmonary function tests (PFTs) during the period that the veteran had elevated eosinophilia. The first PFTs were in October 1961, two years post spontaneous pneumothorax and thoracotomy. He noted that while the PFTs were reported to have been within normal limits, he wondered if they might have been low for a 29 year old. The only other set of PTFs was in August 2000, and were compatible with moderate airflow obstruction. No definitive diagnosis as to the cause of the veteran's airflow obstruction has ever been identified. The physician offered the following conclusions: eosinophilia was a manifestation of a number of conditions and not a distinct disease entity and, in itself, did not cause any symptoms. The etiology of the veteran's eosinophilia in service was never identified. Eosinophilia was not a feature of, caused, or aggravated COPD. Eosinophilia was seen in some patients with asthma and "asthmatic bronchitis," but the veteran's history was not compatible with asthma. There was no direct evidence in the record that the veteran had what is conventionally referred to as COPD in 1953-54. He noted that the veteran had borderline low PFTs and symptoms by age 29-30, and that it was conceivable that these subclinical obstructive changes were present earlier. However, spontaneous pneumothorax is relatively common in young adult men and usually results from a rupture of apical bullae. The exact pathogenesis of these type lesions remained unclear. In this case, the veteran had three x-ray studies from 1952-55 which were normal, and a 10x12 cm cyst was first discovered in the right middle lobe in 1959. He commented that either the cyst was overlooked on the earlier films or it expanded at some point between 1955 and 1959, and then ruptured. He indicated that while the etiology of the veteran's eosinophilia and airflow obstruction was not be identified, he opined that it was very unlikely that they were related. Also, while the date of onset of the veteran's airflow obstruction could not be ascertained from the available data, there was no clinical evidence of COPD during service. A letter from Dr. Bash, received in September 2003 opined, in essence, that the veteran's pulmonary fibrotic, adhesive, emphysematous/obstructive process (symptoms of COPD) was caused by a disease, which was first manifest by eosinophilia during service. Further discussion of Dr. Bash's opinion will be addressed in the analysis section of this decision. A copy of information on the subject of eosinophilia from an Internet site was associated with the claims file in April 2004. On VA pulmonary examination in May 2004, it was noted that the claims file was reviewed and a detailed medical history was included in the report. The description of the veteran's medical history was the same as described above and will not be repeated. The veteran reported that he was diagnosed with asthma by a private physician, Dr. Basheda, in 2000. Laboratory studies from August 2003 showed eosinophilia of one percent and within normal range. Alpha 1-antitrypsin level was negative in 2002. PFTs were consistent with mild to moderate obstructive airway disease and were similar to the results from June 2002. The examiner, a certified registered nurse practioneer (CRNP), indicated that the case was reviewed with a physician. She opined that it was apparent that the veteran had an undetermined lung disease associated with eosinophilia in service, but that the symptoms did not support a diagnosis of asthma or COPD. In fact, findings from spirometry and PFTs in 2002 did not support a diagnosis of asthma. She noted that bullous lung disease was present from 1992, and opined that it was likely of a congenital origin or from an early lifetime factor. A VA examination for hemic disorders was conducted in June 2004. The examination report included a detailed description of the veteran's medical history and current findings. Laboratory studies showed no evidence of eosinophils. The examiner noted that the veteran had eosinophilia of undetermined etiology in service, a spontaneous pneumothorax in 1959 which revealed a cyst, and no evidence of eosinophilia since 1959. No diagnosis or opinion was rendered. VA PFTs in July 2002 and June 2004 were not significantly different and revealed mild obstructive airway disease without bronchodilator response. In a letter received in August 2004, Dr. Bash stated that the veteran's medical records show that his initial pulmonary symptoms began in service and were associated with eosinophilia. He believed that the veteran's in-service eosinophilia caused structural damage to his lung which resulted in his current chronic bullous/fibrotic lung diseases with very poor pulmonary function, and that his opinion was consistent with the evidence of record. A letter from H. G. Butler, M.D., retired, received in August 2004, indicated that he had reviewed the medical records he received from Dr. Bash and strongly agreed with his opinion. Dr. Butler opined that the veteran's current lung disease started in service manifested by eosinophilia and a fever of unknown etiology. He noted that the veteran was hospitalized in service for an acute febrile illness associated with chest and back pains, and that this event was as likely as not the onset of chronic eosinophilia and lifelong pulmonary disease. In September 2004, the claims file was referred to a VA specialist in hemic disorders for an opinion regarding the nature and etiology of the veteran's current lung disorder and, in particular, whether there was any relationship between the current lung disorder and the eosinophilia in service. The physician indicated that he had reviewed the claims file in its entirety. He noted that eosinophilia can be a distinct disease or secondary to another disease process. Usually eosinophilia is associated with parasitic disease, neoplastic diseases, collagen vascular, allergic, or other systemic diseases. It can also be seen with exposure to drugs or parasites or in proteins and heavy metals. The secondary reactive eosiniphilias are transient manifestation that do not enter the host. Primary idiopathic eosinophilia, such as, hypereosinophilic syndromes most often resulted in tissue injury and organ failure. The physician noted that hypereosinophilic syndromes are usually seen in patients who have several different symptoms and is a chronic disease usually with frequent remission, relapses, diverse complications, or damage to the tissue and multiple organ systems primarily because of the chronicity of the disease and the frequent relapses. The eosinophilia and myalgia are also chronic disease with hypereosinophilias and usually characterized by arthralgias, dyspnea, cough, swelling or the extremities, and maculopapular, uriticaria, and fascicular rash. Some patients have hepatomegaly, cardiac failure, and arrhythmias. Pulmonary eosinophilias are disease that are classified as diseases whether it is a parenchymal infiltration of the eosinophils. Patients with reactive pulmonary eosinophilia, also know as Lvffler's syndrome, usually have phase IgE-mediated tissue response and elevated serum concentrations of IgE. He noted that eosinophilia, by itself, cannot cause and does not worsen COPD. The physician indicated that veteran's eosinophilia was from August 1954 to February 1955, and opined that it was not capable of causing or worsening any COPD. He noted that there was no way to determine if the veteran had Lvffler's syndrome or acute eosinophilia in service, but in any event, neither process would be expected to cause problems with prolonged fibrosis, and neither are chronic diseases. During service, the veteran was evaluated and ruled out for parasitic infections and there was no evidence that he was exposed to any drugs, foreign proteins, or heavy metals. The reason for his eosinophilia in service was unknown. If the veteran had hypereosinophilic syndrome, then he would have expected to see frequent remissions and relapses with more problems such as anorexia, weight loss, fever, sweating, splinter hemorrhages, etc., at the time he was first seen. He opined that there was no evidence that the veteran had asthma or COPD in service. Laws & Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Secondary service connection may be granted for a disability which is proximately due to or the result of a service- connected disability. 38 C.F.R. § 3.310(a) (2004). Additionally, secondary service connection may be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 8 Vet. App. 374 (1995). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that he still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494- 95 (1997). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). Analysis Lung Disorder The veteran contends, in essence, that his eosinophilia in service was a manifestation of a chronic lung disorder which was first shown several years after service. The service medical records showed no complaints, treatment, abnormalities, or diagnosis referable to any respiratory or lung disorder. The veteran was treated for chronic flank pain of one-month duration in August 1954. Except for elevated eosinophils, all diagnostic studies, including cardiolipin, urinalysis, a throat culture, three stools, and a muscle biopsy were within normal limits. It is significant to note that the veteran made no mention of any current or past history of respiratory problems, and no lung abnormalities were noted on examination at that time. Similarly, the veteran made no mention of any respiratory or lung problems when examined by VA in February 1955, two months after his discharge from service. His only complaint was an occasional backache. A chest x-ray study at that time was normal and laboratory studies showed eosinophilia of 10 percent. The diagnoses included eosinophilia and pyuria. The first evidence of any respiratory problem was in 1959, when the veteran suffered a spontaneous right pneumothorax and underwent wedge resection of a congenital cyst in the middle lobe to repair the air leak. On admission in October 1959, the veteran reported that he was in good health and that he had no problems since service until September 1959, when he awoke with severe anterior chest pain. Subsequent VA medical reports in October 1961 and March 1964 showed no pertinent lung pathology other than residuals of the pneumothorax surgery. Chest x-ray studies were essentially normal and showed no evidence of lung disease. Laboratory studies showed eosinophilia of one and two percent, respectively, which are considered well within normal limits. Furthermore, the veteran's service entrance and separation chest x-ray films were reviewed by a VA radiologist in June 1960, and by the VA Director of Radiology Services in November 1964. Both radiologist's opined that there was no evidence of any pulmonary pathology in service. The latter physician noted that parasitic disease or some allergic disease such as asthma, can cause a pulmonary cyst, but that there was no evidence of either disease in service. Therefore, there was no relationship between the pulmonary cyst and eosinophilia. The first indication of lung problems was noted on a VA outpatient note in November 1992. The veteran was noted to have slight airway obstruction when coughing, manifested by slight wheezing when examined by VA in 1971. However, there was no evidence of moist rales, rhonchi, or wheezing on restful breathing, and no diagnosis of a respiratory or lung disorder was indicated. The evidence in favor of the veteran's claim consists of three private medical opinions by Drs. Basheda, Butler, and Bash. Dr. Basheda has been treating the veteran for respiratory problems since sometime in 2000, and rendered a diagnosis of asthma related to military service. He provided no discussion of the relevant facts and offered no analysis for his conclusion. While he stated that the veteran developed a respiratory illness associated with eosinophilia in service which, according to old records, was most likely asthma, it appears that his opinion was based largely on self-described history provided by the veteran as there is no evidence of any respiratory symptoms or illness in service. (See August 2000 letter). As noted above, the service medical records clearly showed no complaints, abnormalities, or diagnosis of any respiratory problems or lung disorder during service. A bare conclusion, even when reached by a health care profession, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998); Reonal v. Brown, 5 Vet. App. 458, 461 (1999) (A medical opinion based on an inaccurate factual premise is not probative.) Thus, the Board finds the opinion of Dr. Basheda is of no probative value. The opinion of Dr. Butler was based on medical reports provided by the veteran and consisted principally of information from the reports of Dr. Bash. Dr. Butler stated, inaccurately, that the veteran was hospitalized in service with acute febrile illness associated with chest and back pains. He went on to reiterate the veteran's medical history as described by Dr. Bash, and concluded that the febrile (fever) illness marked by eosinophilia in service marked the onset of his life long pulmonary disease. The service medical records do not show that the veteran was seen for acute fever associate with chest and back pain, but rather for chronic flank pain, alone. While the veteran reported a single incident of chills and sweats about a month prior to admission, he said that he had no further symptoms since that time. In fact, there is no evidence that the veteran had any symptoms or manifestations of a febrile illness during service. Furthermore, Dr. Butler offered no explanation or analysis for his conclusion nor did he provide any rationale as to the possible relationship between the veteran's eosinophilia in service and the later developed respiratory disorders. A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Turning to Dr. Bash, the Board finds that his opinion is based largely on speculation and unsubstantiated theories and is of little probative value. Dr. Bash makes inferences and assumptions, which he characterizes as fact, and selectively chooses evidence that supports his position while ignoring pertinent facts which run contrary to his position. The Board is not bound to accept a medical opinion based on speculation, unsupported by clinical data, or on an inaccurate factual premise. Id; Reonal, 5 Vet. App. at 461 (1999); Black v. Brown, 5 Vet. App. 177, 180 (1993). Dr. Bash opined that the veteran's chronic pulmonary fibrotic, adhesive, emphysematous/obstructive process (symptoms of COPD) was caused by a disease which was first manifest by eosinophilia during service. However, he offers no suggestion as to the nature of the "disease" nor did he identify any objective evidence to support his hypothesis. He asserts that the veteran was "very ill" at the time of the eosinophilia episode in service and that eosinophilia is know to occur in certain types of chest pathology. His characterization of being "very ill" is a misstatement of fact. The service medical records noted that he did not appear to be ill and that his only complaint was chronic flank pain and frequency. Furthermore, his reference to eosinophilia and chest pathology in the same sentence leaves the reader with the impression that some type of chest pathology was present. The impression is reinforced by his August 2004 letter in which he stated, unabashedly, that "according to the medical record" pulmonary symptoms were present in service and were associated with eosinophilia. Again, a misrepresentation of fact. There is not a scintilla of evidence in the record suggesting that the veteran had any respiratory problems or pulmonary symptoms during service or until nearly five years after service. All diagnostic studies, including chest x-rays were normal. There was no evidence of any pulmonary pathology in service or when examined by VA within the first year after service, and additional diagnostic studies specifically ruled out any parasitic infections, including trichinosis. Dr. Bash also stated that his opinion was supported by nearly all of the medical opinions of record with minor discrepancies, which he stated were probably due to incomplete facts, incomplete diagnostic factual evaluations, incomplete correlation with pathological factual data, and incomplete definitions of COPD and/or incomplete literature reviews. He asks the Board to disregard certain aspects of the medical opinions offered by various VA physicians which are contrary to his position, but to accept those statements which support his opinion. It is interesting to note that while Dr. Bash highlighted his credentials as an expert in radiology and his proficiency interpreting x-ray studies and other diagnostic imaging procedures, he has offered no explanation as to the absence of any radiological evidence to support his opinion that the veteran had a respiratory disease in service or that eosinophilia "caused structural damage to his lungs . . ." (see 8/04 letter). As noted above, the service chest x-ray studies, more precisely, the actual photoroentgenograms as opposed to just the examiner's report, were reviewed by a radiologist in 1960 and by the Chief of Radiology Services in 1964. Both radiologists found no evidence of any pulmonary pathology. Likewise, there was no evidence of any pulmonary abnormalities on the post-service chest x-ray study in February 1955. These facts were completely ignored by Dr. Bash. The issue before the Board involves the etiology the veteran's eosinophilia, a blood disorder, and the relationship, if any, to his later developed chronic lung disease. As a radiologist, Dr. Bash's opinion on a matter requiring expertise in hematology and pulmonology, is of limited probative. On the other hand, the claims file was reviewed by VA specialists in pulmonary and hemic diseases in May 2003 and September 2004, respectively. Both specialists stated, unequivocally that COPD is not caused or aggravated by eosinophilia, and that there was no evidence of COPD in service. The pulmonologist opined that it was very unlikely that the veteran's eosinophilia and airflow obstruction were related. The hematologist stated that the etiology of the veteran's eosinophilia in service was unknown, despite numerous diagnostic testing. Both specialists included a detailed analysis of the facts and evidence of record and considered possible alternative causes for the veteran eosinophilia in service. Although neither could offer an opinion as to the precise etiology of the veteran's eosinophilia, both agreed that there was no evidence of a respiratory disorder in service and no objective evidence showing a relationship between eosinophilia and the veteran's current lung disorder. The Board finds that the opinions of the VA specialists are more persuasive than the speculative opinions by the private doctors as they were based on a comprehensive review of all of the evidence, including the contrary opinions, and included a discussion and analysis of all relevant facts. The record shows that the VA specialists also considered alternative theories, but did not find sufficient evidence in the record to support a causal relationship between the veteran's current lung disorder and service or to the service-connected eosinophilia. The Board finds that the two VA pulmonary examinations (June 2002 and May 2004), which offered opinions suggesting a relationship between the veteran's current lung disorder and his eosinophilia in service are unpersuasive and, more importantly, not supported by any objective evidence. Both opinions were confusing and contradictory. Moreover, neither opinion included any clinical data or analysis of the facts to support the conclusions reached. The June 2002 opinion indicated that the veteran's asthma and COPD were casually related to the service-connected eosinophilia, since it was not uncommon to manifest eosinophilia at various stages of illness. Yet, he went on to say that there was no evidence of asthma in service or until at least 20 years after service, and that he could not offer an opinion as to whether there was any pulmonary pathology during service. He also offered a convoluted assessment that it was unlikely that the veteran's bullous lung disease was present in service, but that since it is a congenital disease, it was more likely than not that the lung pathology was present during service. The May 2004 opinion was authored by a certified registered nurse practioneer, who is not shown to have any medical expertise on the subject of hematology or pulmonary disorders. Although she indicated that the case was reviewed with a physician, the report does not include the physician's signature or indicate that he was in agreement with her diagnosis. This is significant in that she concluded that the veteran had an undetermined lung disease in service associated with eosinophilia, a fact not supported by any objective evidence of record. As noted above, a bare conclusion, even when reached by a health care profession, is not probative without a factual predicate in the record. Miller, 11 Vet. App. at 348 (1998); see also Reonal, 5 Vet. App. at 461, (1999); Bloom, 12 Vet. App. at 187 (1999); Black, 5 Vet. App. at 180 (1993). In reaching this decision the Board has considered the doctrine of reasonable doubt. However, as the overwhelming evidence of record, including the assessments and opinions of the various physicians who have evaluated the evidentiary record from 1960 to the present and in particular, the most recent expert opinions, is against the veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for a lung disorder is denied. Eosinophilia-Myalgia with gastric residuals & Dry Eye Syndrome The veteran asserts that he has eosinophalia myalgia syndrome with gastric residuals and dry eye syndrome secondary to his service-connected eosinophilia. The service medical records showed that the veteran was seen on one occasion for an upset stomach in November 1954. He denied any nausea, diarrhea, or pain, and no tenderness was found on examination. The assessment was indigestion, and he was given soda bicarbonate. The veteran was hospitalized for bilateral flank pain of one-month duration in August 1954. On examination, there was some cost vertebral angle tenderness, slightly more on the left. The remainder of the examination was within normal limits. An x-ray study revealed slight scoliosis of the lumbar spine with convexity to the left. All other clinical and diagnostic studies were within normal limits. The service medical records show no further complaints, treatment, abnormalities, or diagnosis referable to any gastrointestinal or back problems, and no symptoms or findings referable to any eye problems. His separation examination in December 1954 showed his eyes, pupils, ocular motility, spine and musculoskeletal system were normal. Except for left varicocele, his and gastrourinary system was also normal. Uncorrected visual acuity was 20/20, bilaterally. The veteran made no mention of any gastrointestinal problems, dry eye, or back problems on his original application for VA compensation benefits in January 1955, and, except for a history of low back pain, no pertinent abnormalities were noted on examination in February 1955. The examination report specifically noted that the veteran denied any GU problems. The veteran made no mention of any myalgia type pain, including back pain, or any gastrointestinal or eye problems when hospitalized of a spontaneous pneumothorax in October 1959, and no pertinent abnormalities were noted on examination. The veteran reported that his back bothered him and that he had a stiff neck when examined by VA in September 1971, but no pertinent abnormalities were found. On examination, his muscles were well developed and there was no fasciculation or fibrillation. There was no localized atrophy, and his back, neck, and extremity joints were entirely within normal limits. His eyes and digestive systems were normal. A diagnosis of gastroesophageal reflux (GER) was noted on a VA outpatient report in October 1982. At that time, the veteran reported eructation with certain foods over the past year, relieved somewhat with antacids. Subsequent progress notes showed treatment for GER with over-the-counter medications. UGI series in May 1995 showed no evidence of hiatal hernia or gastroesophageal reflux. A small ulcer crater in the duodenal bulb was suspected. However, subsequent outpatient notes continued to show assessments of GER. VA x-ray studies in May and December 1996, revealed marked rotolevoscoliosis of the lumbosacral spine, discogenic disease of L4-5, and mild to moderate spondylosis of the cervical spine. In the instant case, the veteran has provided no competent evidence to support his claim that he has myalgia syndrome with gastric residuals or dry eye syndrome secondary to his service-connected eosinophilia. The evidentiary records shows marked scoliosis and discogenic disease of the lumbosacral spine, spondylosis of the cervical spine, and a suspected duodenal ulcer. While he has been evaluated by VA on numerous occasions, including on VA examinations in June 2002, and May and June 2004, there were no diagnoses or opinions relating any of his symptoms, including back pain and digestive problems to his service-connected eosinophilia. Similarly, the numerous VA eye clinic outpatient records and VA examinations have failed to show any complaints, findings, or diagnosis of dry eye. The veteran, as a layperson, is not competent to offer an opinion as to medical causation or etiology. Epps v. Brown, 9 Vet. App. 341 (1996); Espiritu, 2 Vet. App. 492 (1992). See also Franzen v. Brown, 9 Vet. App. 235 (1996). As there is no competent evidence of myalgia, gastric symptoms, or dry eye syndrome which is shown to be related to his service-connected eosinophilia, the Board finds no basis to grant service connection. Accordingly, service connection for eosinophalia myalgia syndrome with gastric residuals and dry eye syndrome secondary to service-connected eosinophilia is denied. Increased Rating 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Based on the evidence of record, the Board finds that a compensable rating for eosinophilia is not warranted. The record does not contain competent medical evidence that the veteran has eosinophilia or any ascertainable residuals of the hemic or lymphatic systems which are shown to be related to eosinophilia. All of the medical evidence associated with the claims file during the pendency of this appeal have failed to reveal any symptoms or residuals of eosinophilia. The evidentiary record shows that eosinophilia has not been demonstrated since 1959, and recent VA hematology studies in August 2003, showed no evidence of eosinophilia. In the absence of active disease or any residual disability, such as liver or spleen damage, the Board finds that there is no basis to award a compensable rating. Accordingly, the appeal is denied. ORDER Service connection for a lung disorder is denied. Service connection for eosinophalia myalgia syndrome with gastric residuals is denied. Service connection for dry eye syndrome secondary to service- connected eosinophilia is denied. An compensable evaluation for eosinophilia is denied. RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs