Citation Nr: 1300547 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 07-37 806 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama THE ISSUE Entitlement to service connection for a bilateral eye disorder, including as secondary to medication for service-connected tension headaches. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from January 1983 to September 2000. This case comes to the Board of Veterans' Appeals (Board) on appeal from a February 2005 decision by the RO in Montgomery, Alabama that denied service connection for history of dry eyes with corneal abrasions, status post surgical intervention. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran's claim requires further development before being decided. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Although the Board sincerely regrets the additional delay that inevitably will result as a consequence of this remand, this additional development of her claim is necessary to ensure that there is a complete record upon which to adjudicate this claim and to afford her every possible consideration. Service connection is permissible on a direct basis for disability that was incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran contends that she has dry eyes with corneal abrasions due to medication (Depakote and Elavil) which she says were prescribed for her service-connected migraine headaches. In this regard, the Board notes that the Veteran is not service-connected for migraine headaches, but rather is service-connected for tension headaches. Medical evidence on file reflects that the Veteran has been treated for various eye disorders, including dry eyes, anterior corneal dystrophy, meibomian gland dysfunction (MGD), and keratoconjunctivitis sicca (KCS). She has been treated for eye disorders by Dr. J. at Maxwell Air Force Base, who referred her to Dr. Z., a private physician, for eye surgery. In June 2003, Dr. J. diagnosed questionable anterior dystrophy of the right eye, tear deficiency bilaterally, and resolving H. simplex keratitis in the left eye. In July 2003, he indicated that he thought the diagnosis of H. simplex was incorrect, and diagnosed anterior corneal dystrophy, MGD (questionably secondary to the first diagnosis), and KCS (questionably secondary to the first diagnosis). He referred the Veteran to Dr. Z., who diagnosed anterior membrane dystrophy in both eyes, and later performed phototherapeutic keratectomy in both eyes. In November 2003, Dr. Z. indicated that her visual acuity was substantially improved and her symptoms were resolving. Medical records from Maxwell Air Force Base also reflect treatment for migraine headaches, with medications including Zomig, amitryptyline, and Depakote. A VA eye examination was conducted in December 2004. It does not appear that the examiner reviewed the claims file, since he did not state that this was done, and, moreover, based his opinion solely on the Veteran's reported history and on the information contained in the examination request he received from the RO. There is no indication that he reviewed her claims file or medical records, and, in fact, additional relevant medical records were associated with the claims file after the examination was completed. The VA examiner indicated that the Veteran claimed "increase in service-connection for corneal dystrophy or secondary to medications taken for other service-connected conditions." The examiner indicated that the Veteran was taking Elavil and Depakote for stress, and that these medications she was taking for stress had caused her eyes to dry. He also stated that after a clinical examination, he found no residuals of the corneal scraping or residuals of the recurrent corneal erosion. Her eyes had healed, and there did not appear to be any significant residuals of those activities. She did have dry eyes, which is most likely caused or the result of her Depakote and Elavil. He also stated that he did not see a corneal dystrophy, but rather saw a corneal insult. He said that in his personal opinion, somehow he did not feel that there has been any significant increase in the recurrent corneal erosion process. In July 2006, Dr. J. diagnosed anterior corneal dystrophy in both eyes associated with KCS in both eyes, and said that the Veteran's primary problems now are all related to KCS with MGD. The Board finds that the December 2004 VA medical opinion is both confusing and inadequate, as it is not based on a review of the Veteran's claims file and medical records, as the examiner provided conflicting conclusions as to whether or not the Veteran has a current eye disability. Therefore, another medical opinion is necessary prior to appellate review. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Lathan v. Brown, 7 Vet. App. 359 (1995); 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4)(i) (2012). A VA examination and opinion is needed to assist in determining the etiology of any current eye disorder(s), including whether it was caused or aggravated by her service-connected tension headaches or medication used to treat these headaches, or is otherwise related to her military service. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Supporting medical nexus evidence generally is needed to associate a claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); McQueen v. West, 13 Vet. App. 237 (1999); and Velez v. West, 11 Vet. App. 148, 158 (1998). The examiner should be asked to review the claims file and all pertinent medical records, including the additional medical records from Maxwell Air Force Base dated from 2004 to 2007 that were added to the claims file after the December 2004 examination, which the VA compensation examiner obviously could not have reviewed. Ongoing relevant medical records should also be obtained, as it does not appear that all of the relevant medical records are on file. In a November 2007 statement, the Veteran reported that she had been treated for her eye disorders by Dr. J., then Dr. Z., and by Dr. D.M., with another appointment scheduled for December 2007. The most recent medical records on file are dated in June 2007. Some of these identified medical records are not on file, and attempts should be made to obtain them. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Finally, the RO/AMC should send the Veteran appropriate notice regarding the information and evidence not of record that is necessary to substantiate the claim for service connection for an eye disorder, including as secondary to a service-connected disability. See 38 U.S.C.A. § 5103(a); 38 C.F.R. §§ 3.159, 3.310. The September 2004 notice letter relates only to the information and evidence necessary for direct service connection. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with corrected notice pursuant to 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 regarding her claim for service connection for an eye disorder, including as secondary to service-connected disabilities, with notice of the amendments to 38 C.F.R. § 3.310. 2. Contact the Veteran and ask her to provide the names and addresses of all medical care providers who have treated her for an eye disorder. After securing any necessary releases, obtain any records which are not duplicates of those in the claims file. In particular, obtain pertinent medical records from Maxwell Air Force Base, dated since June 2007. 3. Schedule a VA ophthalmological examination of the Veteran to determine the etiology and date of onset of any current eye disorder. All indicated studies should be performed. The examiner must review the claims file and should note that review in the report. The examiner should also respond to the following questions: Based on the examination and review of the record, what is the likelihood (very likely, as likely as not, or unlikely) that any current eye disorder is related to her military service, or alternatively is secondary to her already service-connected tension headaches, meaning proximately due to, the result of, or alternatively, aggravated (chronically worsened) by her service-connected tension headaches (or the medication used to treat these headaches)? The examiner should indicate all current eye diagnoses, and should provide a rationale for all expressed opinions. 4. Then, readjudicate the claim. If the claim remains denied, provide a supplemental statement of the case to the Veteran and her representative, and allow an opportunity for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter 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 (CONTINUED ON NEXT PAGE) 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. 2012). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).