Citation Nr: 1301241 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 08-23 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for left eye retinal detachment. 2. Entitlement to service connection for right eye retinal detachment and cataract removal. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD James Alsup, Counsel INTRODUCTION The Veteran served on active duty from February 1971 to February 1974. Service in Vietnam is evidenced in the record. This matter comes before the Board of Veterans Appeals (Board) on appeal from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, that, among other things, denied service connection for left eye retinal detachment, right eye retinal detachment and cataract of the right eye. The Veteran disagreed and perfected an appeal. In June 2010, the Veteran presented testimony at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is included in the Veteran's VA claims folder. In a September 2010 decision, the Board remanded the claims at issue for further development. 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 September 2010 remand required VA to provide an eye examination to evaluate whether the Veteran's current eye disabilities were at least as likely as not incurred in or otherwise related to active service and if not, the examiner was asked to opine whether it was at least as likely as not that any current eye disability, to include postoperative retinal detachment of both eyes status post central retinal vein occlusion left eye with secondary cataract of the right eye, was either caused or permanently aggravated beyond the natural progression of the disease as a result of the Veteran's service-connected diabetes mellitus. The Veteran was examined by a VA ophthalmology resident in October 2010. The examiner provided an opinion that retinal detachment of both eyes was less likely as not related to the Veteran's service and was not caused or aggravated by the Veteran's service-connected diabetes mellitus. There was, however, no explanation regarding how the examiner reached the conclusions or what medical basis there was for the opinions. The Veteran was then granted service connection in an April 2012 rating decision for left eye central vein occlusion with mild cataract and assigned a 20 percent evaluation effective January 18, 2005. As the Veteran has not, to the Board's knowledge, disagreed with this determination, the issue is not before the Board at this time and the issues on appeal are those shown on the title page. The Court has held that once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the medical evidence is insufficient to allow adjudication of the issues on appeal. Moreover, the Board finds that the October 2010 examination report does not satisfy the requirements of the Board's September 2010 remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition, VA medical records dated from June 2003 to November 2004 should be requested as the Veteran reported that he had cataract surgery in 2004. Moreover, VA treatment records dated November 24, 2008 and December 10, 2004 indicate that scanned information pertaining to the eyes is available. These documents should be made available for review. It is also noted that on remand, the Veteran did not authorize the release of any private medical records. On remand, the Veteran should be asked to submit or authorize the release of any relevant private medical records, including those of Dr. Pafumy. Accordingly, the case is REMANDED for the following action: 1. Obtain the following VA treatment records: a. a non-VA ophthalmology note dated November 24, 2008 (see VA treatment record dated November 24, 2008, indicating a nonVA ophthalmology note was scanned via VistA imaging), b. an image that was scanned into the Veteran's VA medical records on December 10, 2004 (see VA ophthalmology progress note dated December 10, 2004), and c. VA treatment records dated from June 2003 to November 2004. 2. Request that the Veteran submit or authorize the release of any private medical records that are relevant to his claims including the medical records of Dr. Pafumy. If, after making reasonable efforts to obtain named records the AMC is unable to secure same, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 3. Then, return the Veteran's VA claims folder to the VA examiner who authored the October 2010 compensation and pension examination report regarding the Veteran's eyes or, if that examiner is not available, provide the Veteran's VA claims folder to another appropriate medical provider. The examiner should review the Veteran's VA claims folder and provide an addendum to the October 2010 report as follows: a. Is it at least as likely as not (a probability of 50 percent or greater) that the Veteran's right eye retinal detachment with cataract removal began in or is related to the Veteran's active service. Please provide a complete explanation for the opinion. b. Is it at least as likely as not that the Veteran's right eye retinal detachment with cataract removal was caused by the Veteran's service-connected diabetes mellitus. Please provide a complete explanation for the opinion. c. Is it at least as likely as not that the Veteran's right eye retinal detachment with cataract removal was aggravated beyond the natural progression of the disease by the Veteran's service-connected diabetes mellitus. Please provide a complete explanation for the opinion. d. The examiner should also provide an opinion whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran's left eye retinal detachment began in or is related to the Veteran's active service. Please provide a complete explanation for the opinion. e. Is it at least as likely as not that the Veteran's left eye retinal detachment was caused by the Veteran's service-connected diabetes mellitus. Please provide a complete explanation for the opinion. f. Is it at least as likely as not that the Veteran's left eye retinal detachment was aggravated beyond the natural progression of the disease by the Veteran's service-connected diabetes mellitus. Please provide a complete explanation for the opinion If the examiner determines that an examination of the Veteran is required in order to provide the requested opinions, such an examination should be accorded. 4. Complete the foregoing, ensure the addendum is adequate, and conduct any other development deemed necessary, then readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, prepare a supplemental statement of the case and, if otherwise in order, return the Veteran's VA claims folder to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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. 2012). _________________________________________________ S. S. TOTH 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).