Citation Nr: 1228186 Decision Date: 08/15/12 Archive Date: 08/21/12 DOCKET NO. 06-25 374 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to an increased rating for diabetes mellitus, rated as 20 percent disabling prior to December 27, 2010, and 60 percent thereafter. 2. Entitlement to service connection for an eye disability, other than diabetic retinopathy, manifested by recurrent hemorrhaging. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from March 1986 to January 1995. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, which denied a rating in excess of 20 percent for diabetes mellitus with retinopathy, and from an August 2005 rating decision of the RO in Honolulu, Hawaii, which denied service connection for a disability claimed as bleeding in the eyes. In an October 2010 decision, the Board granted service connection for right and left hand disabilities, secondary to his service-connected diabetes mellitus. The remaining issues on appeal-entitlement to a rating in excess of 20 percent for diabetes mellitus with retinopathy and entitlement to service connection for an eye disability, other than diabetic retinopathy, manifested by recurrent hemorrhaging-were remanded to the RO for additional evidentiary development. While the matter was in remand status, in a November 2010 rating decision, the RO effectuated the Board's October 2010 decision and granted service connection for right and left diabetic hand syndrome and peripheral neuropathy of the upper extremities. As best the Board can discern, the RO assigned an initial 10 percent disability rating for diabetic right hand syndrome, effective June 2, 2004, and then recharacterized the appellant's previously service-connected diabetes mellitus with retinopathy as diabetes mellitus with retinopathy, diabetic left hand syndrome, and peripheral neuropathy of the bilateral upper extremities, and confirmed the 20 percent rating previously assigned. Before the matter was returned to the Board, in a November 2011 rating decision, the RO increased the rating for the appellant's diabetes mellitus with retinopathy, diabetic left hand syndrome, and peripheral neuropathy of the bilateral upper extremities, to 40 percent, effective December 27, 2010. Thereafter, in an April 2012 rating decision, the RO recharacterized the appellant's service-connected diabetes mellitus disability as diabetes mellitus with diabetic retinopathy, erectile dysfunction, and diabetic renal nephropathy with proteinuria, and increased the rating for that disability to 60 percent, effective December 27, 2010. In addition, the RO assigned a separate 10 percent rating for diabetic left hand syndrome, effective June 2, 2004. For reasons which are unclear, the RO did not include the appellant's service-connected peripheral neuropathy of the right and left upper extremities as part of the diabetic process in assigning the 60 percent rating for his service-connected diabetes mellitus disability, nor was his upper extremity peripheral neuropathy separately rated. As set forth in more detail below, the Board has corrected that omission. Although a higher rating for the appellant's diabetes mellitus disability has been granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned nor has the appellant withdrawn his appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Moreover, given the RO's actions, complete adjudication of the appellant's claim now requires analyses during discrete time periods, as set forth above on the cover page of this decision. FINDINGS OF FACT 1. For the entire appeal period, the appellant's diabetes mellitus has required careful monitoring of his blood sugar multiple times daily; three to six injections of insulin daily; a prescribed diabetic diet; episodes of ketoacidosis and hypoglycemic reactions; and multiple documented complications, including complications that would be compensable if separately evaluated such as diabetic renal nephropathy with proteinuria and hypertension requiring continuous medication for control and peripheral neuropathy of the right and left upper extremities. 2. The most probative evidence shows that the appellant does not have an eye disability, other than diabetic retinopathy, including an eye disability manifested by recurrent hemorrhaging. CONCLUSIONS OF LAW 1. The criteria for a 100 percent rating for diabetes mellitus have been met during the entire appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.119, Diagnostic Code 7913 (2011). 2. An eye disability, other than diabetic retinopathy, manifested by recurrent hemorrhaging, was not incurred in active service and is not causally related to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In a May 2004 letter issued prior to the initial decision on the claim, VA notified the appellant of the information and evidence needed to substantiate and complete his claim for an increased rating, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. In a February 2005 letter issued prior to the initial decision on the claim, VA notified the appellant of the information and evidence needed to substantiate and complete his claim of service connection for an eye disability, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2011). In a March 2006 letter, the RO sent the appellant a letter for the express purpose of advising him of the additional notification requirements imposed by the U.S. Court of Appeals for Veterans Claims (Court) in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In January 2008, the RO sent the appellant a letter for the express purpose of complying with the Court's decision in Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). Since the issuance of these letters, the RO has reconsidered the appellant's claims of multiple occasions, most recently in the April 2012 Supplemental Statement of the Case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2011). The appellant has not argued otherwise. The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159(c)(2), (3) (2011). The appellant has also been afforded multiple VA medical examinations in connection with his claim, most recently in July 2010. 38 C.F.R. § 3.159(c) (4) (2011). The Board finds that the medical examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate). In that regard, the examinations were performed by qualified medical professionals and the examination reports contain the necessary physical findings upon which to decide the issue on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994) (holding that VA medical examination reports must provide sufficient reference to the pertinent schedular criteria); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). The Board notes that the appellant has not challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F3d 1362 (Fed. Cir. 2011) (holding that in the absence of a challenge, the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issues now being decided. Again, the appellant has not argued otherwise. Background The appellant's service treatment records show that he was diagnosed as having diabetes mellitus in July 1994. His records are silent for any indication of an eye disability manifested by recurrent hemorrhaging. At his October 1994 military separation medical examination, the appellant's eyes were normal on clinical evaluation, including his pupils and ocular motility. Ophthalmoscopic examination was also normal. His uncorrected distant vision was 20/30 on the right and 20/20 on the left. Uncorrected near vision was 20/20, bilaterally. In January 1995, in connection with his separation from active service, the appellant submitted an application for VA compensation benefits seeking service connection for diabetes mellitus and vision loss. In connection with his claim, the appellant underwent VA medical examination in March 1995, at which he was diagnosed as having diabetes mellitus, controlled with insulin. No complications were identified. An eye examination showed that the appellant did not have retinopathy. His ocular health was normal. The diagnoses were diabetes mellitus without retinopathy and refractive error, myopia, both eyes, not service-related. In an August 1995 rating decision, the RO granted service connection for diabetes mellitus, and assigned an initial 20 percent rating, effective January 28, 1995, the day following the date of his separation from active service. The RO denied service connection for vision loss, explaining that refractive error of the eyes was not a disability within the meaning of applicable regulations providing for payment of VA disability compensation benefits. See 38 C.F.R. §§ 3.303, 4.9 (2011). In August 2002, the appellant submitted a claim for an increased rating for his service-connected diabetes mellitus. In connection with his claim, the RO obtained VA and military clinical records, dated from December 1997 to January 2003 showing continued treatment for diabetes mellitus as well as notations of diabetic retinopathy. In an April 2003 rating decision, the RO recharacterized the appellant's disability as diabetes mellitus with retinopathy and continued the 20 percent rating assigned. In May 2004, the appellant submitted his most recent claim for an increased rating for his service-connected diabetes mellitus, stating that his disability had worsened. In a June 2004 statement, the appellant reiterated that his condition was getting worse. He also reported multiple complications of diabetes mellitus, including erectile dysfunction and numbness and tingling in his arms and legs. In support of his claim, the RO obtained VA clinical records, dated from February 2003 to July 2004 showing continued treatment for diabetes mellitus. In pertinent part, these records show that the appellant's medications included twice daily injections of insulin, which were increased to three times daily in December 2003. He was also prescribed medication for hypertension. Additionally, the appellant was prescribed a diabetic diet but exhibited poor compliance. He was noted to have a history of two episodes of diabetic ketoacidosis, most recently in December 2000. During this period, it was noted that the appellant was working as a carpenter and going to culinary school. The appellant underwent VA medical examination in June 2004 at which he reported that he had been diagnosed as having diabetes mellitus in service and started on insulin at that time. He reported a period of hospitalization in 1999 for an episode of ketoacidosis. He reported that he had also been diagnosed as having erectile dysfunction, peripheral neuropathies, and retinopathy. The diagnoses included insulin dependent diabetes, renal insufficiency with microalbuminuria, erectile dysfunction, and neuropathy in the bilateral lower extremities. A VA eye examination in July 2004, the appellant was noted to have mild diabetic retinopathy and a history of atrophic retinal holes in the right eye, status post laser treatment, stable. His vision was correctable to 20/20. No other eye disability was identified. In an October 2004 rating decision, the RO confirmed and continued the 20 percent disability rating for diabetes mellitus with retinopathy. The RO also granted service connection for peripheral neuropathy of the right and left lower extremities and assigned initial 10 percent disability ratings, effective June 2, 2004. The RO also granted service connection for renal insufficiency and erectile dysfunction and assigned initial zero percent ratings for each disability, effective June 2, 2004. In a February 2005 statement, the appellant indicated that in addition to diabetic retinopathy, he had periodic bleeding in his eyes, the most recent episode of which had been approximately six months prior. He also indicated that had had an operation on his eyes to close some holes. Additional VA clinical records show continued treatment for diabetes mellitus with complications. The appellant visited his diabetic care provider approximately every two months and his medications included insulin injections four times daily. He continued to work and attend school. In December 2004, the appellant was seen for a diabetic retinal examination. He was noted to have mild nonproliferative diabetic retinopathy in both eyes. His medications were noted to include four injections of insulin daily. The assessment was insulin dependent diabetes mellitus, poorly controlled, with mild nonproliferative diabetic retinopathy in both eyes, no clinically significant macular edema. Also diagnosed was chorioretinal scar, right eye, status post retinal laser treatment for hole, stable. In February 2005, the appellant was treated for diabetic hand syndrome. In a January 2006 letter, the appellant's VA physician described the appellant's diabetic hand syndrome as severe and indicated that it caused the appellant difficulty in continuing in his education in the culinary arts, as it was a hand-intensive discipline. During a May 2006 primary care visit, the appellant was diagnosed as having diabetes mellitus with retinopathy, microalbuminuria, carpal tunnel sydrome, and impotence. During a visit to the rheumatology clinic in July 2006, the appellant was noted to have a past medical history significant for diabetes mellitus with renal and ophthalmic manifestations, diabetic hand syndrome, carpal tunnel syndrome, tendosynovitis, and erectile dysfunction. It was noted that as a result of his hand symptoms, he no longer did much carpentry work and concentrated mostly on culinary work instead. In October 2006, it was noted that the appellant had graduated from culinary school. He obtained a full time job as a baker and chef. At an August 2007 VA medical examination, it was noted that the appellant probably had low grade diabetic neuropathy in all four extremities. At a VA medical examination in August 2007, the appellant reported that he had had diabetes mellitus since 1995. He indicated that he had an episode of ketoacidosis approximately 10 years ago. The diagnoses included diabetes with complications including peripheral neuropathy. Subsequent VA clinical records document continued treatment for diabetes mellitus with complications. In June 2009, the appellant was seen in connection with his bilateral diabetic hand syndrome with neuropathy and severe carpal tunnel syndrome. It was noted that he had been treated with physical therapy and steroid injection and that surgery was now recommended. The examiner described the appellant's hand symptoms as progressive. The appellant declined surgery, stating that he could not take time off from work. In September 2009, it was noted that the appellant's medications now included insulin injections five times daily. In October 2009, the appellant was noted to have diabetes mellitus, hypertension, hyperlipidemia, lower extremity peripheral neuropathy, and worsening bilateral diabetic hand syndrome with components of carpal tunnel syndrome, tenosynovitis, and neuropathy. In August and September 2010, the appellant was seen for seizure like activity which was determined to be a probable hypoglycemic event. In a November 2010 rating decision, the RO granted service connection for right and left diabetic hand syndrome and peripheral neuropathy. As set forth above, the RO assigned an initial 10 percent disability rating for diabetic right hand syndrome, effective June 2, 2004. In addition, the RO recharacterized the appellant's service-connected diabetes mellitus with retinopathy as diabetes mellitus with retinopathy, diabetic left hand syndrome, and peripheral neuropathy of the bilateral upper extremities and confirmed the 20 percent rating previously assigned. In December 2010, the appellant underwent VA eye examination. The examiner noted that the appellant had a history of a refractive error with a corrected visual acuity of 20/20, bilaterally. He also had insulin dependent diabetes mellitus, poorly controlled, with mild nonproliferative retinopathy in both eyes and a scar on the right eye secondary to laser treatment of a retinal hole, stable. After examining the appellant and reviewing his claims folder, the examiner indicated that the appellant exhibited no other eye abnormalities related to diabetes mellitus. He advised the appellant to return for another diabetic eye examination after one year. At a VA diabetes examination in December 2010, the examiner noted that the appellant had widely fluctuating blood sugar levels on a daily basis as well as symptomatic hypoglycemia at least three times weekly. The appellant reported that he had been having increased episodes of hypoglycemic seizures in which he had to rely on his friends and family for help. The examiner also noted that the appellant had a history of hospitalization in 2010 for a hypoglycemic reaction and treated himself with four to six doses of insulin daily. The examiner noted that the appellant had been told to follow a diabetic diet but no calorie restriction. The examiner also noted that the appellant had to avoid strenuous activities in order to prevent hypoglycemic episodes. With respect to complications, the appellant reported increasing numbness and burning in his fingers and toes which affected his work. He also had erectile dysfunction and was on Lisinopril. The diagnoses were diabetes mellitus, type I, with the following complications: peripheral neuropathy of the right and left upper and lower extremities, erectile dysfunction, renal nephropathy, diabetic retinopathy. The examiner indicated that the appellant's diabetes mellitus had a moderate negative effect on his occupation and daily activities due to widely varying blood glucose levels requiring testing and treatment. Subsequent VA clinical records show that the appellant continued to receive treatment for diabetes mellitus with complications. His medications included insulin injections six times daily as well as medication for hypertension. In a November 2011 rating decision, the RO increased the rating for the appellant's diabetes mellitus with retinopathy, left diabetic hand syndrome, and peripheral neuropathy of the bilateral upper extremities to 40 percent, effective December 27, 2010. In December 2011, the appellant again underwent VA medical examination. The examiner noted that the appellant had features of both type I and type II diabetes mellitus with multiple documented complications. He required careful monitoring of his blood sugar multiple times daily. The examiner indicated that the appellant had diabetic peripheral neuropathy with constant pain in the upper extremities and mild intermittent pain in the lower extremities. All extremities exhibited moderate numbness and paresthesias. Deep tendon reflexes were decreased and light touch and vibration were absent in the hands, ankles and feet. Sensation to cold was decreased in the upper extremities and absent in the lower extremities. The examiner described the appellant as having mild incomplete paralysis in the median nerves and sciatic nerves bilaterally. The appellant was also noted to have diabetic nephropathy with microalbuminuria, renal dysfunction with persistent proteinuria, and erectile dysfunction. In an April 2012 determination, the RO recharacterized the appellant's service-connected diabetes mellitus disability as diabetes mellitus with diabetic retinopathy, erectile dysfunction, and diabetic renal nephropathy with proteinuria, and increased the rating for that disability to 60 percent, effective December 27, 2010. In addition, the RO assigned a separate 10 percent rating for diabetic left hand syndrome, effective June 2, 2004. For reasons which are unclear, the RO did not include the appellant's service-connected peripheral neuropathy of the right and left upper extremities as part of the diabetic process in assigning the 60 percent rating for his service-connected diabetes mellitus disability, nor was his upper extremity peripheral neuropathy separately rated. Entitlement to an increased rating diabetes mellitus, rated as 20 percent disability prior to December 27, 2010, and 60 percent thereafter. Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2011). Separate diagnostic codes identify the various disabilities. 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 (2011). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (2011). 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 (2011). 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 (2011); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Diabetes mellitus is rated pursuant to the criteria set forth at 38 C.F.R. § 4.119, Diagnostic Code 7913 (2011). Under those criteria, a 20 percent rating is assigned when diabetes mellitus requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned when diabetes mellitus requires insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned when diabetes mellitus requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities, (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note (1) following Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. Analysis Applying the criteria set forth above to the facts in this case, the Board finds that the manifestations of the appellant's service-connected diabetes mellitus more nearly approximate the criteria for a 100 percent disability rating for the entire appeal period. As set forth above, the record corresponding to the appeal period shows that the appellant's diabetes mellitus has required careful monitoring of his blood sugar multiple times daily as well as three to six daily injections of insulin. He has been prescribed a diabetic diet and the record documents periods of hospitalization for ketoacidosis and hypoglycemic reactions. More recently, the appellant's diabetes mellitus has required him to restrict his activities in order to prevent hypoglycemic reactions. Nonetheless, he has continued to experience episodes of hypoglycemia at least three times weekly as well as hypoglycemic seizures. In addition to these manifestations of diabetes mellitus, the record documents multiple additional longstanding complications of diabetes mellitus, including diabetic retinopathy, diabetic right and left hand syndrome, carpal tunnel syndrome, diabetic renal nephropathy, peripheral neuropathy of the upper and lower extremities, and erectile dysfunction. The record shows that the RO has recognized and separately rated the appellant's diabetic right hand syndrome, diabetic left hand syndrome, peripheral neuropathy of the right lower extremity, peripheral neuropathy of the left lower extremity. Each of these disabilities has been assigned a 10 percent disability rating, effective June 2, 2004. The ratings assigned to these disabilities are not at issue in the present appeal. In addition to the separate compensable complications of the appellant's diabetes mellitus discussed immediately above, the record shows that the RO has also recognized several additional complications of the appellant's diabetes mellitus apparently determined to be noncompensable, including diabetic retinopathy, erectile dysfunction, diabetic renal nephropathy, and peripheral neuropathy of the upper extremities. The Board finds, however, that the record contains sufficient information upon which to conclude that the appellant's peripheral neuropathy of the right and left upper extremities is manifested by symptoms which would warrant compensable ratings, as is his diabetic nephropathy. In that regard, the record documents that during the entire appeal period, the appellant's upper extremity peripheral neuropathy has been manifested by symptoms such as pain, numbness, and tingling in the upper extremities, comparable to mild, incomplete paralysis of the median nerve. Under 38 C.F.R. § 4.124a, Diagnostic Code 8515, such symptomatology warrants a compensable rating for each extremity. Additionally, such symptoms appear to be separate from the additional symptoms associated with his service-connected diabetic hand syndrome, including decreased grip strength and loss of dexterity. Additionally, the Board notes that diabetic nephropathy is evaluated under Diagnostic Code 7541. Under these criteria, renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease process is rated as renal dysfunction. 38 C.F.R. § 4.116, Diagnostic Code 7541. The criteria for rating renal dysfunction provide a noncompensable rating where the disability is manifested by albumin and casts with history of acute nephritis; or noncompensable hypertension under Diagnostic Code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. 38 C.F.R. § 4.115a. Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. In this case, as set forth above, the record documents that during the entire period of the claim, the appellant has had diabetic nephropathy with microalbuminuria and his been on prescribed medication (Lisinopril) for control of hypertension. In considering the manifestations of the appellant's service-connected diabetes mellitus discussed above, including daily injections of insulin three to six times daily plus restriction of activities, together with the multiple documented complications that are separately compensable, including peripheral neuropathy of the upper extremities and diabetic renal nephropathy with proteinuria and hypertension, the Board finds that the record reflects that the appellant's diabetes mellitus disability with diabetic retinopathy, erectile dysfunction, and diabetic renal nephropathy manifested by symptoms of proteinuria, more nearly approximates the criteria for a 100 percent rating under Diagnostic Code 7913 for the entire appeal period. 38 U.S.C.A. § 5107(b) ; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for an eye disability other than retinopathy manifested by recurrent hemorrhaging. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2011). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2011). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2011). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Analysis The appellant seeks service connection for a bilateral eye disability, claimed as recurrent bleeding in his eyes. As set forth above, the appellant's service treatment records are negative for findings of an eye disability manifested by recurrent bleeding. At his October 1994 military separation medical examination, the appellant's eyes were examined and found to be normal. As delineated in detail above, the post-service record on appeal is similarly negative for complaints or findings of a chronic eye disability manifested by recurrent bleeding. The appellant was diagnosed as having diabetic retinopathy with a history of successful laser surgery for retinal holes, as well as a refractive error. Repeated examinations, however, have shown that no other eye disability is present. As noted, service connection is already in effect for diabetic retinopathy and a refractive error is not a disability for VA compensation purposes. 38 C.F.R. §§ 3.303, 4.9 (2011). The Board has carefully considered the appellant's statement to the effect that he experienced episodes of bleeding in his eyes, but concludes that the repeated findings of VA examiners that the appellant does not manifest an eye disability other than diabetic retinopathy and a refractive error are entitled to more probative weight. Based on the foregoing evidence, the Board finds that a bilateral eye disability manifested by recurrent bleeding was not present in service and that the most probative evidence shows that the appellant does not currently have any eye disability manifested by recurrent bleeding which is causally related to his appellant's active service or any incident therein, or causally related to or aggravated by any service-connected disability, including diabetes mellitus. There is also no evidence of continuous symptomatology since service. The Board thus finds that the preponderance of the evidence is against the claim of service connection for an eye disability other than retinopathy manifested by recurrent hemorrhaging. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a 100 percent rating for diabetes mellitus with diabetic retinopathy, erectile dysfunction, and diabetic renal nephropathy, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for an eye disability other than retinopathy manifested by recurrent hemorrhaging is denied. ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs