Citation Nr: 1123547 Decision Date: 06/21/11 Archive Date: 06/28/11 DOCKET NO. 08-12 567 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial compensable evaluation for prostatitis. 2. Entitlement to service connection for an eye disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Katz, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1980 to July 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2007, November 2008, and December 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office in North Little Rock, Arkansas (RO). In February 2011, the Veteran submitted additional evidence pertinent to his claims. In April 2011, the Veteran's representative provided a waiver of his right to have the RO readjudicate his claims with the additional evidence. See 38 C.F.R. § 20.1304(c) (2010). FINDINGS OF FACT 1. Since the initial grant of service connection, prostatitis has been manifested by daytime urination every two to three hours and nighttime urination two times per night. 2. The weight of the probative evidence of record shows that the Veteran's eye disorder is related to active duty service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable evaluation of 10 percent, but no more, for prostatitis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115a (2010); 38 C.F.R. § 4.115b, Diagnostic Code 7527 (2010). 2. An eye disorder was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has certain notice and assistance requirements. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Upon receipt of a substantially complete application for benefits, VA must notify the Veteran of what information or evidence is needed in order to substantiate the claim, and it must assist the Veteran by making reasonable efforts to obtain the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With regard to the Veteran's claim for entitlement to an initial compensable evaluation for prostatitis, prior to an October 2010 readjudication of the Veteran's claim, letters dated in December 2006, May 2008, and November 2009 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded, Vazquez-Flores v. Shinseki, No. 2008-7150 (Fed. Cir. Sept. 4, 2009); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by the issuance of a fully compliant notification letter followed by a re-adjudication of the claim). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. - (2009). The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, VA medical treatment records, and identified private medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the Veteran was provided with VA examinations with regard to his claim and he has not indicated that he found any of these examinations to be inadequate. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the January 2010 VA examination provided in this case to be adequate, as it provides sufficient detail to determine the severity of the Veteran's service-connected prostatitis in accordance with the pertinent rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Without deciding whether notice and development requirements have been satisfied in the present case, the Board is not precluded from adjudicating the issue involving the Veteran's claim for entitlement to service connection for an eye disorder. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. This is so because the Board is taking action favorable to the Veteran by granting entitlement to service connection for an eye disorder. As such, this decision poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); see also Pelegrini, 17 Vet. App. 412 ; VAOPGCPREC 16-92, 57 Fed. Reg. 49, 747 (1992). I. Prostatitis By a March 2007 rating decision, the RO granted service connection for prostatitis and assigned a noncompensable evaluation, effective August 1, 2006, under the provisions of 38 C.F.R. § 4.115b, Diagnostic Code 7599-7527. In May 2007, the Veteran filed a notice of disagreement contesting the noncompensable evaluation, and in April 2008, he perfected his appeal. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2010). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2010); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Veteran's claim for entitlement to an initial compensable rating for prostatitis is based on the assignment of an initial rating for a disability following the initial award of service connection for that disability. As such, evidence contemporaneous with the claim and the initial rating decision is most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. The Veteran's prostatitis is currently assigned a noncompensable rating pursuant to Diagnostic Code 7599-7527. The hyphenated codes are intended to show that the Veteran's prostatitis is rated analogously to prostate gland injuries, infections, hypertrophy, and postoperative residuals under Diagnostic Code 7527. See 38 C.F.R. § 4.20 (2010) (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous); 38 C.F.R. § 4.27 (2010) (unlisted disabilities rated by analogy are coded first by the numbers of the most closely related body part and then "99"). Under Diagnostic Code 7527, prostatitis must be rated as voiding dysfunction or urinary tract infection, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7527. Voiding dysfunction is evaluated under the three subcategories of urine leakage, urine frequency, and obstructed voiding. 38 C.F.R. § 4.115a. For urine leakage, a 20 percent evaluation is warranted for the wearing of absorbent materials which must be changed less than 2 times per day; a 40 percent evaluation is assigned for the wearing of absorbent materials which must be changed 2 to 4 times per day; and a maximum 60 percent evaluation is assigned for the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Id. For urinary frequency, a 10 percent evaluation is assigned when there is daytime voiding interval between two and three hours, or; awakening to void two times per night. Id. A 20 percent evaluation is assigned when there is daytime voiding interval between one and two hours, or; awakening to void three to four times per night. Id. A maximum 40 percent evaluation is assigned for daytime voiding intervals of less than one hour or awakening to void five or more times per night. Id. For obstructed voiding, a 10 percent evaluation is assigned when there is marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post void residuals greater than 150 cc; (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec); (3) recurrent urinary tract infections secondary to obstruction; or (4) stricture disease requiring periodic dilation every two to three months. Id. A maximum 30 percent evaluation is assigned when there is urinary retention requiring intermittent or continuous cathertization. Id. Urinary tract infections are rated as 10 percent disabling when they require long-term drug therapy, one to two hospitalizations per year, and/or require intermittent intensive management. Id. A 30 percent evaluation is warranted when there is recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Id. If urinary tract infections result in poor renal function, the disorder is rated as renal dysfunction. Id. The Veteran's service treatment records reflect numerous complaints of and treatment for prostatitis prior to 2005. Although these records were reviewed and considered, they are not relevant to the level of the Veteran's prostatitis on and after his discharge from service. However, the records dated within the year preceding the Veteran's discharge from service are more relevant to the determination of the appropriate disability evaluation, and are discussed below. An April 2005 service treatment record indicates that the Veteran had difficulty urinating. He noted intermittent stream which burned, and that he had to strain to release urine. The diagnosis was prostatitis, and the Veteran was prescribed pain medication and Ciprofloxacin. Another April 2005 treatment record reflects that the Veteran complained of a lump over his left testicles and that he woke up with burning pain two days before. There was no dysuria, and there was minimal pain. The diagnosis was testicular pain. A May 2005 treatment record notes the Veteran's complaints of pain during urination, and he stated that he had to bear down. Examination revealed no erythema or drainage and no hernia. The Veteran was referred for a consultation with urology. The Veteran underwent a testicular ultrasound in May 2005, which was within normal limits. Another May 2005 treatment record indicates that a testicular ultrasound was within normal limits but there were small bilateral hydroceles. A fourth May 2005 treatment record reflects that the Veteran complained of difficulty with urination, increased pressure, and dribbling when attempting to urinate. He denied drainage. The record indicates that the Veteran had a history of enlarged prostate, and that urinalysis was negative. In September 2005, the Veteran complained of groin pain and swelling for one week. He also stated that he had pain during urination. He denied taking medication for the problem. An undated service treatment record notes the Veteran's complaints of pain and burning while urinating for one month. The record indicates that the Veteran was given medication six days before for the problem. A September 2005 retention/separation examination reflects that the Veteran's prostate was dodgy and tender to palpation, and that he had chronic prostatitis. In a report of medical history, completed at that time, the Veteran reported a history of frequent or painful urination and kidney stone or blood in urine due to prostatitis. In December 2006, the Veteran underwent a VA examination. The Veteran reported a history of chronic prostatitis, and complained of perineal pain, testicular pain, and perineal burning. He also noted intermittent dysuria. Physical examination revealed the Veteran to have mild tenderness over all areas of the abdomen. The abdomen was soft without masses. There were no abnormal pulsations or bruits, and the femoral pulsations were normal. External genitalia were also normal except for hemorrhoids. The diagnoses included chronic prostatitis. In a May 2007 notice of disagreement, the Veteran reported that his prostatitis symptoms included difficulty starting urination (hesitancy), weak stream, and dribbling. He also reported that he had a frequent and urgent need to urinate, and that he urinated approximately every three hours during the day. He also noted that he awoke to urinate twice at night. The Veteran stated that he found it difficult to pass urine, that he had increased pressure on his bladder to start and produce a spattering stream, and that he had pain and burning while urinating. In a June 2007 private medical treatment letter, C.G.K., M.D. reported that the Veteran's irritable bowel disease and hemorrhoid disease were "most likely exacerbating the chronic prostatitis." Dr. C.G.K. noted his recollection that the Veteran could not urinate around a catheter for Video Urodynamic Testing, and opined that the most likely cause would be either stricture disease or bladder sphincter dyssynergia, both of which exacerbate chronic prostatitis. Dr. C.G.K. further reported that the Veteran had a history of recurrent infections and urinary hesitancy. He noted that he did "not understand how you would not meet the 10% criterion" for prostatitis. He suggested that the Veteran should review the urodynamic results which were preformed elsewhere, as it was his "guess . . . that there is a physiologic obstruction demonstrable on those tests." In an August 2007 letter, K.P., M.D. reported that the Veteran had nocturia two times "probably sequelae of prostatic edema." Dr. K.P. further reported that the Veteran strained when he urinated, and that it was most probably due to prolonged prostatitis. An August 2007 VA treatment record reflects that the Veteran had a history of prostatitis with Levaquin use. In a May 2009 hearing before the Board, the Veteran testified that his prostatitis symptoms included urinary frequency. He noted that he urinated every two to three hours during the day, and that he urinated three times during the night. He reported that he could not stand to pee, and had to sit. He explained that a weak stream dribbled out and splattered, and that it took him about two minutes to start urinating. He indicated that the stream stopped and started, and that he eventually was able to get all of it out. He stated that he was not taking any medications for his prostatitis. He also denied having to use adult diapers. In January 2010, the Veteran underwent another VA examination. The Veteran reported that he had an average of about three to four episodes per year of prostatitis, and that his last episode was in 2007. The Veteran complained of urinary tract symptoms which lasted from 10 to 30 days which are treated with fluids and which go away on their own. He also noted a history of kidney stones with lithotripsy. He denied any lethargy, weakness, anorexia, and weight loss. He reported that he emptied his bladder every two to three hours during the day and twice at night. He reported some mild hesitancy and decrease in stream. He denied dysuria unless he had a prostate infection, and he denied dribbling. He denied incontinence and use of absorbent material and appliances. There was no history of urinary tract surgery other than prostate biopsy. The Veteran reported a history of recurrent urinary tract infections, averaging three to four per year. There was no history of hospitalizations for the prostate, no neoplasms, and no history of nephritis. The Veteran has not required cathertizations or dilations. There were no drainage procedures, and no diet. The Veteran reported that he was a full-time student, and that he did not miss any classes because of his prostate symptoms. Physical examination revealed the abdomen to be soft. The liver, spleen, and kidneys were not palpable. The abdomen was nontender and there were no abnormal bruits or pulsations. The external genetalia were normal. Scrotal contents were normal and there was no hernia. Rectal examination was unremarkable. The prostate was normal in size, shape, and consistency, and nontender. The diagnoses were chronic prostatitis, renal calculi, and lower urinary tract symptoms. The examiner categorized the severity of the Veteran's prostatitis as mild and intermittent, and noted that, although symptomatic at times, the Veteran has not restricted his life or daily activities as a result of his prostatitis. In a November 2010 statement, the Veteran reported that his prostatitis symptoms included difficulty starting urination (hesitancy), weak stream, dribbling, and frequent and urgent need to urinate. He reported that he urinated every three hours during the day and twice at night, and that he had constant burning urination. He stated that his treating physician recommended that he stop regular antibiotic treatment for prostatitis and that he allow acute episodes to resolve by increasing fluid intake and bear the discomfort for seven to ten days before seeking treatment unless complete obstruction occurs. After a thorough review of the evidence of record, the Board concludes that an initial evaluation of 10 percent, but no greater, is warranted for the Veteran's prostatitis. 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7527. Specifically, although the Veteran has repeatedly denied the use of absorbent materials, he consistently reported that his prostatitis caused urinary frequency of voiding every three hours during the day and awakening to urinate twice at night. While the Veteran indicated during his May 2009 hearing before the Board that he urinated three times per night, the majority of the evidence of record suggests that the Veteran only awoke twice per night to urinate. Specifically, in a May 2007 notice of disagreement, the Veteran reported that he urinated every three hours during the day and two times at night. An August 2007 private medical treatment record notes that the Veteran had nocturia two times per night. During a January 2010 VA examination, the Veteran reported that he urinated every two to three hours during the day and two times at night. Last, in a November 2010 statement, the Veteran again stated that he urinated every three hours during the day and two times at night. Thus, although the Veteran once reported that he urinated three times per night, the Board accords more weight to the numerous statements provided by the Veteran that he only awakes two times per night to urinate. Accordingly, a 10 percent evaluation is warranted under 38 C.F.R. § 4.115a for urinary frequency. 38 C.F.R. § 4.115a. However, an evaluation in excess of 10 percent is not warranted for the Veteran's prostatitis. During his January 2010 VA examination, the Veteran reported a history of recurrent urinary tract infections, averaging three to four per year. Nevertheless, there is no lay or medical evidence that the Veteran's recurrent urinary tract infections have required long-term drug therapy, hospitalization, or intermittent intensive management. 38 C.F.R. § 4.115a. Also, there is no evidence that the Veteran requires the use of absorbent materials or an appliance, or that he had urinary retention requiring intermittent or continuous cathertization. Id. Last, there is no medical or lay evidence that the Veteran voids every one to two hours during the day. As discussed, the Board does not accord significant weight to the Veteran's May 2009 statement that he urinates three times per night, as the majority of the Veteran's statements indicate that he only urinates twice per night. Accordingly, an initial evaluation in excess of 10 percent is not warranted under 38 C.F.R. § 4.115a. The Board has also considered the Veteran's symptoms which are not specifically contemplated by the Rating Schedule, such as intermittent stream, burning, straining, increased pressure, and dysuria. While those symptoms certainly contribute to the impairment caused by the Veteran's prostatitis, they do not show voiding dysfunction, urinary frequency, obstructed voiding, or urinary tract infection impairment sufficient to warrant an evaluation in excess of 10 percent. Mauerhan, 16 Vet. App. 436. For the foregoing reasons, an initial evaluation greater than 10 percent for service-connected prostatitis is not warranted. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's prostatitis is not so unusual exceptional in nature as to render the rating for this disorder inadequate. The criteria by which the Veteran's prostatitis is evaluated specifically contemplate the level of impairment caused by that disability. Id. As demonstrated by the evidence of record, the Veteran's prostatitis is manifested by daytime urination every two to three hours and nighttime urination two times per night. When comparing this with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluation regarding the Veteran's prostatitis is not inadequate. An evaluation greater than 10 percent is provided for certain manifestations of prostatitis, but the medical evidence reflects that those findings are not present in this case. Therefore, the schedular evaluation is adequate and no referral is required. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of 10 percent for the Veteran's service-connected prostatitis at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Fenderson, 12 Vet. App. at 126. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected prostatitis, the evidence shows no distinct periods of time since service connection became effective, during which the Veteran's prostatitis has varied to such an extent that a rating greater or less than 10 percent would be warranted. Cf. 38 C.F.R. § 3.344 (2010) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). II. Eye Disorder The Veteran contends that his current eye disorder is related to active duty service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), VA may award service connection where a claimant can demonstrate "(1) that a condition was 'noted' during service; (2) evidence of postservice continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology." Barr, 21 Vet. App. at 307. A claimant may rely on lay evidence "to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492, F.3d 1372, 1377 (Fed. Cir. 2007) (footnote omitted). "[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Veteran's service treatment records reflect complaints of and treatment for floaters in his eyes during active duty service. A July 1979 entrance examination reveals that the Veteran's eyes were normal. In a report of medical history, completed at that time, the Veteran denied a history of eye trouble. Examinations dated in June 1988 and November 1989 show that the Veteran's eyes were normal. In reports of medical history, completed in June 1988 and November 1989, respectively, the Veteran denied a history of eye trouble. In October 1991 and April 1995 reports of medical history, the Veteran denied a history of eye trouble. In November 2001, the Veteran complained of floaters during a routine optometry examination. He denied flashes. The diagnoses included astigmatism, hyperopia, and "normal ocular health, other than floaters." An August 2002 service treatment record indicates that the Veteran complained of floaters. A December 2002 treatment record notes that the Veteran reported a two-year history of floaters. The diagnosis was vitreous floaters, longstanding. In July 2004, the Veteran underwent a routine optometry examination. The diagnosis was hyperopic astigmatism with pressure. In a self-administered questionnaire, the Veteran reported a history of blurry vision, but denied eye pain; double vision; burning, itching, or tearing; seeing flashing lights; seeing floating spots, and headaches. In an April 2005 optometry questionnaire, the Veteran reported a history of seeing flashing lights or floating spots. An April 2005 treatment record notes that the Veteran reported eye burning at night with reading. The diagnosis was normal ocular health. A September 2005 retention/separation examination reflects that the Veteran's eyes were normal. However, in a report of medical history, completed at that time, the Veteran complained of eye disorder or trouble, which he described as floaters in both eyes for the prior six years. An October 2005 service treatment record notes the Veteran's complaints of trouble with near vision. He reported that he had floaters, but denied blurriness. He also noted burning and tearing. Examination of the eyes showed that the pupils were equal, round, and reactive to light and accommodation. The diagnosis was compound myopia astigmatism with presbyopia. A January 2006 treatment record notes that the Veteran had pain behind his eyes and felt dizzy. In December 2006, the Veteran underwent a VA examination. The Veteran reported a history of having floaters in his eyes. Physical examination showed visual acuity with correction at far of 20/20 in the right eye and 20/15-2 in the left eye. Visual acuity with correction at near with Rosenbaum near card was J2- at 14 inches in the right eye and J+ at 14 inches in the left eye. The Veteran's working glasses were -0.25 sphere +0.50 cylinder at axis 100 in the right eye and -0.50 sphere +0.75 cylinder at axis 055 in the left eye. The addition power was +1.50 in the right eye and +1.25 in the left eye. Visual acuity without correction at far was 20/20 in both the right and left eyes. Visual acuity without correction at near with Rosenbaum near card was 20/70 at 14 inches in the right and 20/50-2 in the left eye. A manifest refraction was obtained with the best corrected near and far visions was -0.25 sphere +0.25 cylinder at axis 100 in the right eye with visual acuity of 20/15-2. The left eye had a prescription of -0.50 sphere +0.75 cylinder at axis 0.47 with a visual acuity of 20/15- in the left eye. At near with an addition power of +1.50 the visual acuity was 20/20 at 16 inches in the left. Applanation tonometry was 15 mmHg in both eyes. The extraocular movements were full in both eyes and the visual fields were full to confrontation in both eyes. The pupils were round, reactive to light with negative afferent papillary defect. A slit lamp examination was performed and the lids and lashes were clean in both eyes. The cornea and conjunctivae were clear in both eyes. The irises were normal and the anterior chambers were quiet and deep. The lens showed no lenticular opacities of either eye. A dilated funduscopic examination was performed and cup to disc ratio was 0.2 in both eyes. The macula, vessels, and optic nerve head were within normal limits in both eyes. There was lattice degeneration without holes inferiorly in the left eye and a small area of lattice degeneration superonasally in the left eye. The diagnosis was lattice degeneration in the left eye with complaint of floaters. The VA examiner opined that, although the claims file showed no evidence of lattice degeneration, the "lattice degeneration of the peripheral retina was most likely present at the time of the patient's service." However, the examiner concluded that the Veteran's "floater symptom is most likely due to vitreous degeneration which is a normal aging phenomenon and not documented within the exam found during the patient's military service." In a May 2007 notice of disagreement, the Veteran stated that he first noticed diminished vision due to floaters after he was physically assaulted by an inmate during confinement. He also noted that "there was no complaint of floaters prior to my entry into military service." During a May 2009 hearing before the Board, the Veteran testified that he first noted floaters in his eyes after he was assaulted at the United States Disciplinary Barracks at Fort Leavenworth, and indicated that he still has them. He explained that he was "jumped from behind and beat up" and that, as he was recovering, he noticed that there spots in his vision. He sought treatment, and the ophthalmologist informed him that he had floaters. In January 2010, the Veteran underwent a VA examination. He reported floaters and watery eyes, on and off. He noted that the floaters blocked his vision while reading sometimes. Physical examination revealed the Veteran to have visual acuity with correction at far of 20/20 and 20/20-. Visual acuity with correction at near with Rosenbaum near card was 20/25+2 at 14 inches and 20/20 at 14 inches. The Veteran's working glasses were -0.25 +0.25 at axis 105 and -0.75 +1.00 at axis 100. The power was +1.75. Visual acuity without correction at far was 20/20 and 20/25. Visual acuity without correction at near with Rosenbaum near card was 20/100 at 14 inches and 20/70 at 14 inches. A manifest refraction was obtained and the best corrected visions were -0.25 +0.25 at axis 155 with visual acuity of 20/20, and -0.75 +1.00 at axis 050 with visual acuity of 20/20. At near with an additional power of +2.00, the visual acuity in one eye was 20/20 at 16 inches, and at near with an additional power of +1.75, the visual acuity in the other eye was 20/20 at 16 inches. Applanation tonomerty was 14 mmHg in both eyes. Extraocular movements were full in both eyes and the visual fields were full to confrontation in both eyes. The pupils were equal, round, and reactive to light, bilaterally. A slit lamp examination was performed, and the lids and lashes were clean, bilaterally with mild scurf on the lashes. The cornea and conjunctivae were clear in both eyes. The irises were normal, bilaterally and the anterior chambers were quiet and deep. The lens was also clear, bilaterally. A dilated funduscopic examination was performed, and macula, vessels, and optic nerve head were within normal limits in both eyes. There was a small area of lattice in the right eye and an area of lattice degeneration in the left eye. There was anterior vitreous condensation, bilaterally. The diagnoses were lattice degeneration, bilaterally, vitreous condensation with complaints of intermittent floaters, and mild blepharitis/seborrhea. In a March 2010 addendum, after reviewing the Veteran's claims file, the VA examiner concluded that the Veteran's bilateral lattice degeneration and vitreous condensation with complaints of floaters were "in the service record as reviewed above and therefore were present during his service." The examiner concluded that it would be "conjecture as to the association of his floaters were due to any injury he may have had subsequently without documentation of dates and examinations with complaints associated temporally with such injury." After a thorough review of the evidence of record, the Board concludes that service connection for an eye disorder is warranted. There is evidence of current diagnoses of lattice degeneration and vitreous condensation. See Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). In addition, the Veteran's service treatment records note numerous complaints of and treatment for floaters during active duty service. There is also a finding of longstanding vitreous floaters during active duty service. Thus, there is evidence of inservice incurrence of an eye disorder. Moreover, both the December 2006 and the January 2010 VA examiners found that the Veteran's lattice degeneration was present during service. Although the December 2006 VA examiner concluded that the Veteran's "floater symptom is most likely due to vitreous degeneration which is a normal aging phenomenon and not documented within the exam found during the patient's military service," the January 2010 VA examiner determined that the Veteran's vitreous condensation was present during his active duty service. Moreover, the December 2006 VA examiner's opinion is based on inaccurate factual information. Specifically, although the December 2006 VA examiner stated that there was no evidence of vitreous degeneration during the Veteran's military service, a December 2002 service treatment record reflects a diagnosis of longstanding vitreous floaters. As the December 2006 VA opinion appears to be based on inaccurate facts, the Board affords little probative weight to that opinion. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board must assess the credibility and probative value of the medical evidence in the record). Thus, the only probative medical evidence of record links the Veteran's current lattice degeneration and vitreous condensation to his active duty service. Therefore, with application of the benefit of the doubt doctrine, service connection for an eye disorder is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER An initial evaluation of 10 percent, but no greater, for prostatitis is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for an eye disorder is granted. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs