Citation Nr: 0813502 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 06-05 281 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable rating for hearing loss disability. 2. Entitlement to an initial rating in excess of 10 percent for retropatellar pain syndrome, right knee. 3. Entitlement to service connection for blurry vision. 4. Entitlement to an initial rating in excess of 50 percent for post concussion syndrome with cognitive disorder with personality changes, headaches, insomnia, anosmia, and disequilibrium. 5. Entitlement to service connection for left knee disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The veteran served on active duty from December 1998 to August 2003. This matter comes to the Board of Veterans' Appeals (Board) from a March 2004 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for post concussion syndrome, assigning a 10 percent disability rating, effective September 1, 2003; retropatellar pain syndrome, right knee, assigning a 10 percent disability rating, effective September 1, 2003; bilateral hearing loss disability, assigning a noncompensable disability rating, effective September 1, 2003; and denied entitlement to service connection for tinnitus disability, left knee disability, and blurry vision. A notice of disagreement was filed in February 2005 with regard to the disability ratings assigned and denials of service connection; a statement of the case was issued in December 2005; and, a substantive appeal was received in February 2006. The veteran testified at a RO hearing in April 2006. In a July 2006 rating decision, the RO assigned a 50 percent disability rating to post concussion syndrome, effective September 1, 2003. The issue remains in appellate status, however, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35 (1993). The July 2006 rating decision also granted service connection for tinnitus disability thus constituting a full grant of the benefit sought on appeal with regard to this issue. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The issues of entitlement to service connection for left knee disability, and entitlement to an initial rating in excess of 50 percent for post concussion syndrome with cognitive disorder with personality changes, headaches, insomnia, anosmia, and disequilibrium, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will VA will notify the veteran if any further action is required on his part. FINDINGS OF FACT 1. The veteran has no higher than level I hearing acuity in the right ear and level I hearing acuity in the left ear. 2. The veteran's right knee disability is manifested by pain on motion with minimal functional loss; but without flexion limited to 60 degrees, and no x-ray findings of arthritis, no recurrent subluxation or lateral instability, and no limitation of extension. 3. The veteran's decreased visual acuity is due to myopia and astigmatism and is not a disability for the purposes of entitlement to VA compensation benefits. CONCLUSIONS OF LAW 1. The criteria for the assignment of a compensable rating for bilateral hearing loss disability have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.85, 4.86, Diagnostic Code 6100 (2007). 2. The criteria for entitlement to a disability rating in excess of 10 percent for right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2007). 3. Service connection for decreased visual acuity due to myopia and astigmatism is precluded by governing regulations. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veteran Claims' (Court's) decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, VA satisfied its duties to the veteran in a VCAA letter issued in October 2003. The letter predated the March 2004 rating decision. See id. Since the bilateral hearing loss disability and right knee disability appellate issues in this case (entitlement to assignment of higher initial ratings) are downstream issues from that of service connection (for which the October 2003 VCAA letter was duly sent), another VCAA notice is not required. VAOPGCPREC 8- 2003 (Dec. 22, 2003). The VCAA letter notified the veteran of what information and evidence is needed to substantiate his claims, as well as what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and the need for the claimant to submit any evidence in his possession that pertains to the claims. Id.; but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004). The VCAA letter has clearly advised the veteran of the evidence necessary to substantiate his claims. In March 2006, the veteran was provided with notice of the types of evidence necessary to establish a disability rating and the type of evidence necessary to establish an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Despite initial inadequate notice provided to the veteran, the Board finds no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the appellant has been prejudiced thereby). In any event, since the Board concludes below that the preponderance of the evidence is against entitlement to service connection for blurry vision, and entitlement to higher initial ratings for bilateral hearing loss disability rating and right knee disability, any questions as to the appropriate disability rating and effective date to be assigned are rendered moot. With regard to the issues addressed on the merits in the following decision, the Board also finds that VA has complied with all assistance provisions of VCAA. The evidence of record contains the veteran's service medical records and post-service VA medical records. There is no indication of relevant, outstanding records which would support the veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). Additionally, the evidence of record contains reports of VA examinations performed in January 2004, April 2006, and June 2006. The examination reports obtained are thorough and contain sufficient information to decide the issues on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994). For all the foregoing reasons, the Board concludes that VA's duties to the veteran have been fulfilled with respect to the issues of entitlement to higher initial ratings for bilateral hearing loss disability and right knee disability, and entitlement to service connection for blurry vision.. I. Increased disability ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Hearing loss The current version of the Ratings Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. Table Via will be used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. 38 C.F.R. § 4.85(c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher. 38 C.F.R. § 4.86(b). To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels designated from I for essentially normal acuity, through XI for profound deafness. 38 C.F.R. § 4.85, Tables VI, VII. A noncompensable evaluation is provided where hearing in the better ear is I and hearing in the poorer ear is I through IX; where hearing in the better ear is II, and hearing in the poorer ear is II to IV; or where there is level III hearing in both ears. A 10 percent disability rating is warranted where hearing in the better ear is I, and hearing in the poorer ear is X to XI; or where hearing in the better ear is II, and hearing in the poorer ear is V to XI; or where hearing in the better ear is III, and hearing in the poorer ear is IV to VI.. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. Pertinent case law provides that the assignment of disability ratings for hearing impairment are to be derived by the mechanical application of the Ratings Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). In January 2004, the veteran underwent a VA audiological examination. The veteran reported a history of hearing loss in the left ear since a head injury incurred in service. Pure-tone thresholds for the ears were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 15 25 25 25 LEFT N/A 20 25 25 25 The pure tone average in the right ear was 22 decibels, and 24 decibels in the left ear. Speech recognition scores were 98 percent in the right ear, and 94 percent in the left ear. The examiner stated that hearing is at the upper limits of normal range in both ears; intertest consistency is judged as good. Such findings translate to level I hearing in both ears. 38 C.F.R. § 4.85, Table VI. Applying Table VII, Diagnostic Code 6100, this equates to noncompensable hearing loss. In April 2006, the veteran underwent another VA audiological examination. Pure-tone thresholds for the ears were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 15 15 20 25 LEFT N/A 15 20 20 25 The pure tone average in the right ear was 19 decibels, and 20 decibels in the left ear. Speech recognition scores were 100 percent in both ears. The examiner noted that with regard to the right ear, hearing was within normal limits 250-6000 Hertz with mild sensorineural hearing loss at 8000 Hertz only. With regard to the left ear, hearing was within normal limits 250-4000 Hertz precipitously falling to a moderately severe sensorineural hearing loss 6000-8000 Hertz. Such findings translate to level I hearing in both ears. 38 C.F.R. § 4.85, Table VI. Applying Table VII, Diagnostic Code 6100, this again equates to noncompensable hearing loss. The Board acknowledges the veteran's contentions regarding impact of his hearing loss on his daily activities, and VA's obligation to resolve all reasonable doubt in the veteran's favor. However, as noted previously, because assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered there is no doubt as to the proper evaluation to assign. Lendenmann, supra; 38 C.F.R. § 4.85, Tables VI, VIA, and VII, Diagnostic Code 6100. Applying the audiological test results most favorable to the veteran to the regulatory criteria, the Board is compelled to conclude that the preponderance of the evidence is against entitlement to a compensable rating for bilateral hearing loss disability. Thus, there is no reasonable doubt to be resolved. The veteran may always advance an increased rating claim if the severity of his hearing loss disability should increase in the future. The assignment of an extra-schedular rating was considered in this case under 38 C.F.R. § 3.321(b)(1); however, the record contains no objective evidence that the veteran's bilateral hearing loss disability has resulted in marked interference with earning capacity or employment beyond that interference contemplated by the assigned evaluation, or has necessitated frequent periods of hospitalization. Accordingly, the Board finds that 38 C.F.R. § 3.321 is inapplicable. In summary, for the reasons and bases expressed above, the Board has concluded that a compensable rating is not warranted for bilateral hearing loss disability. Accordingly, the benefit sought on appeal is denied. Right knee It should be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The standardized range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Code 5261. Under Diagnostic Code 5257, pertaining to "other impairment of the knee," a 10 percent rating is warranted for slight knee impairment (recurrent subluxation or lateral instability). A 20 percent rating contemplates a moderate degree of impairment, and a maximum 30 percent rating is warranted for a severe degree of impairment to the knee. Under Diagnostic Code 5256 for ankylosis of the knee, a 30 percent rating is assigned for ankylosis at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating is assigned for ankylosis in flexion between 10 and 20 degrees. A 50 percent rating is assigned for ankylosis in flexion between 20 and 45 degrees. A maximum 60 percent rating is assigned for extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. Under Diagnostic Code 5258, a maximum 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under Diagnostic Code 5259, a maximum 10 percent rating is assigned for symptomatic removal of semilunar cartilage. Diagnostic Code 5262 provides for tibia and fibia impairment. A maximum 40 percent rating is assigned for nonunion of, with loose motion, requiring brace; malunion of with marked knee or ankle disability warrants a 30 percent evaluation; with moderate knee or ankle disability warrants a 20 percent evaluation; and with slight knee or ankle disability warrants a 10 percent evaluation. The RO has assigned a 10 percent disability rating to the veteran's right knee disability under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5260. Service medical records reflect several complaints related to the right knee, and a diagnosis of retropatellar pain syndrome. Objective findings reflected a popping sensation emanating from the right knee, and anterior knee pain. In January 2004, the veteran underwent a VA examination. The veteran complained that his right knee continues to emanate clicking and popping waxes and wanes. He complained that it "hurts" sometimes. He described frequency of once per week or more with a feeling of sensation of "fine cutting, sharp pain in ligaments underneath kneecap." He denied any buckling, locking, swelling, or giving away, and denied that home activities of daily living caused impairment. While working as a furniture stocker, he complained that moving furniture weighing 5-85 pounds was aggravating to the knee. The examiner observed that his bipedal stance and gait were without disturbance, without brace or assistive device. On inspection of the right knee, there were normal anatomic landmarks without edema, swelling, or effusion. Palpation to the medial joint line was nonspecific, medial patellar facet and soft capsular tissues of the medial aspect of the distal femur as aggravating. Active range of motion was flexion to 135 degrees, and extension to 0 degrees. McMurray was nonaggravating, and Lachman was intact. Radiographic studies of the knees was normal. The examiner diagnosed retropatellar pain syndrome, right knee, without subluxation or instability. In June 2006, the veteran underwent another VA examination. He reported pain in the right knee intermittently but at rest it does not bother him. With activity the pain goes up to a 4 out of 10 in severity. His knee is aggravated by standing 30 minutes, walking half a mile, or lifting 50 pounds in weight. His knee is not affected by driving. At rest, he has occasional swelling of the knee, and will occasionally wear a brace for the swelling. The knee does not give way, and he denied taking any medication. On physical examination, range of motion was 0 to 135 degrees. There was slight medial tenderness and some pain with manipulation of the patella. There was no fluid. There was slight crepitus and no laxity. The examiner's impression was retropatellar pain syndrome of the right knee, minimal symptoms, minimal physical abnormality and no progression. The examiner noted that the veteran's right knee has no effect on his condition as a college student. There is no pain on motion of the knees. There is no additional limitation following repetitive use. There is no additional limitation during flare-ups. There is no instability of either knee. An x-ray examination of the knee showed no arthritis or other abnormality. The RO has assigned a 10 percent disability rating to the veteran's right knee, under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for painful motion. Specifically, on examination in January 2004, active range of motion was 135 degrees flexion. Likewise, flexion was also to 135 degrees at the June 2006 VA examination. Strictly adhering to the provisions of Diagnostic Code 5260, such range of motion findings support a noncompensable rating. Thus, it appears that the RO assigned a 10 percent disability in consideration of pain on motion, to include consideration of 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206-07. In light of the veteran's subjective complaints of pain and clicking, the 10 percent disability rating awarded under Diagnostic Code 5260 is warranted. An additional "symbolic" range of motion loss for pain, excess fatigability, decreased functional ability, etc. is not warranted. Diagnostic Code 5003 provides that when the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. The June 2006 x-ray examination showed no arthritis, thus as arthritis of the right knee has not been diagnosed, a disability rating under Diagnostic Code 5003 is not applicable. A compensable rating is not warranted under Diagnostic Code 5257 with respect to the veteran's right knee disability, as there have been no subjective complaints or objective findings of instability. At the January 2004 VA examination, the veteran specifically denied any giving way, and the examiner specifically diagnosed no subluxation or instability. Likewise, at the June 2006 VA examination, the veteran denied giving way, and the examiner stated that there was no instability of the knee. Thus, the evidence does not support assigning an evaluation under Diagnostic Code 5257. According to a recent General Counsel opinion, separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). However, in the present case there is no evidence that a compensable rating is warranted under the criteria of Codes 5260 and 5261 for the knee. Specifically, range of motion findings pertaining to extension have been normal. Thus, there are no findings to warrant a separate 10 percent rating under Diagnostic Code 5261 for the knee. The Board finds that a rating in excess of 10 percent is also not warranted under any alternative provision. Diagnostic Code 5256 provides for a rating in excess of 10 percent, however, application of this code is inappropriate as there is no diagnosis of ankylosis of the right knee. Furthermore, the veteran may not be rated by analogy to this code as he does not suffer functional immobility of the knee. Likewise, Diagnostic Codes 5258 and 5259 are inapplicable, as the clinical evidence does not show that cartilage has been removed or dislocated, nor is there frequent episodes of "locking," pain and effusion into the joint. Additionally, there are no objective findings of impairment of the tibia and fibula, thus there is no basis for a disability rating in excess of 10 percent under Diagnostic 5262, and, genu recurvatum, as rated pursuant to Diagnostic Code 5263, is inapplicable as it has not been diagnosed. The assignment of an extra-schedular rating was also considered in this case under 38 C.F.R. § 3.321(b)(1); however, the record contains no objective evidence that the veteran's service-connected knee disability has resulted in marked interference with earning capacity or employment beyond that interference contemplated by the assigned evaluation, or has necessitated frequent periods of hospitalization. Accordingly, the Board finds that the impairment resulting from the veteran's knee disability is appropriately compensated by the currently assigned schedular ratings and 38 C.F.R. § 3.321 is inapplicable. In summary, for the reasons and bases expressed above, the Board has concluded that a disability rating in excess of 10 percent for retropatellar pain syndrome, right knee, is not warranted. II. Service connection: blurry vision Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in the line of duty or for aggravation of a pre- existing injury or disease in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also 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). For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9; Beno v. Principi, 3 Vet. App. 439 (1992); Veterans Benefits Administration (VBA) Manual M21-1MR ("M21-1MR"), Part III, iv.4.B.10.d. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). The veteran has claimed entitlement to service connection for blurry vision as resulting from a concussion incurred in service. A September 1998 entrance examination reflects that the veteran's distant vision was 20/70 in the right eye and 20/00 in the left eye, corrected to 20/20 in both eyes. Near vision was 20/20 in both eyes. In April 2002, the veteran was assaulted and sustained a concussion, losing consciousness. In the months following the incident, the veteran complained of a myriad of symptoms, to include blurry vision. In January 2004, the veteran underwent a VA examination. The examiner noted review of the claims folder. The chief ocular complaint was noted to be 'decreased distance vision.' Snellen visual acuity uncorrected was 20/200 in both eyes, both corrected to 20/20. The examiner noted the concussion sustained in service 2 years prior. Upon physical examination, the examiner diagnosed myopia, astigmatism - longstanding, corrected with spectacles, and indicated that there were no other ocular findings. While it is clear that during service, the veteran sustained injury to the head resulting in a concussion, and experienced blurry vision subsequent to such injury, the objective medical evidence does not indicate that any current refractive error is due to any superimposed eye disability sustained during service. As the VA examiner stated, the veteran's refractive error is due to his myopia and astigmatism which are corrected with glasses. The examiner did not identify any other ocular findings. Therefore, the veteran's claim of service connection for defective vision is based upon refractive errors of the eye, and the veteran's claim must be denied as a matter of law. ORDER Entitlement to a compensable disability rating for bilateral hearing loss disability is not warranted. Entitlement to a disability rating in excess of 10 percent for retropatellar pain syndrome, right knee, is not warranted. Entitlement to service connection for blurry vision is not warranted. To this extent, the appeal is denied. REMAND At the April 2006 RO hearing, the veteran testified that he is undergoing Chapter 31 vocational rehabilitation due to his post-concussion syndrome, and symptomatology related thereto. Based on a recent medical opinion that the symptomatology related to his post-concussion syndrome may interfere with employment, or affect his ability to maintain employment, the veteran's vocational rehabilitation file is relevant to the claim for a higher initial rating for post-concussion syndrome, and such vocational rehabilitation file should be obtained. Service medical records reflect complaints in July 2001 of bilateral knee pain for 8 months. The assessment was retropatellar pain syndrome. The basis for the March 2004 denial of entitlement to service connection for left knee disability was that there was no objective evidence of a left knee disability. At the June 2006 VA examination, however, objective examination findings pertaining to the left knee reflect flexion limited by 5 degrees, some medial tenderness, and slight crepitus. The examiner diagnosed chronic knee sprain, left, minimal symptoms, minimal physical abnormalities. Although the majority of the service medical records pertain to follow-up treatment for the right knee, in light of the complaints in service pertaining to the left knee and current objective findings pertaining to the left knee, the Board has determined that the veteran should be afforded a VA examination to assess the nature and severity of his claimed left knee disability. The RO should also ensure that proper notice has been issued pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), with regard to the issues being remanded. VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Proper notice, which notifies him of the evidence and information necessary to support his claims must be issued to the veteran. Along with ensuring proper VCAA notice pertaining to his claims, VA is also instructed to provide proper notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). VA should inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted, and an effective date will be assigned if an increased rating is granted, and also include an explanation as to the type of evidence that is needed to establish a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Accordingly, the case is REMANDED for the following actions: 1. The RO should ensure compliance with all notice and assistance requirements set forth in the VCAA and its implementing regulations, to include advising the veteran of the evidence necessary to substantiate his claims, as well as what evidence he is to provide and what evidence VA will attempt to obtain in accordance with Quartuccio v. Principi, 16 Vet. App. 183 (2002). The veteran should also be advised to submit all pertinent evidence in his possession. The notice should include an explanation as to the information or evidence needed to establish a disability rating and an effective date, as outlined by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. The RO should associate the veteran's VA vocational rehabilitation folder with the claims folder. If such efforts prove unsuccessful, documentation to that effect should be added to the claims file. 3. The veteran should be scheduled for a VA examination to ascertain the nature and etiology of left knee disability. It is imperative that the claims folder, to include all service medical records, be reviewed in conjunction with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. After reviewing the claims file and examining the veteran, the examiner should offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that any current left knee disability is related to his active duty service or any incident therein. The examiner should also offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that any current left knee disability is proximately due to or aggravated by the service-connected right knee disability. All opinions and conclusions expressed must be supported by a complete rationale in a report. 4. After completion of the above, the RO should review the expanded record and readjudicate the issues. If any of the benefits sought on appeal remain denied, the veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be remanded to the Board for appellate review. The veteran and his representative have 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. 2007). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs