Citation Nr: 1301619 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 09-15 996 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a vascular disorder, including as secondary to service-connected Diabetes Mellitus, Type II. 2. Entitlement to a rating higher than 10 percent for service-connected nonproliferative diabetic retinopathy of both eyes, with macular edema of right eye and central retinal vein occlusion of the left eye associated with Diabetes Mellitus, Type II. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty in the military from June 1958 to September 1961 and from December 1961 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran's case was previously before the Board in November 2010. He was seeking service connection for central retinal vein occlusion (CRVO), to include as secondary to his service-connected Diabetes Mellitus, Type II. An issue for a rating in excess of 10 percent for diabetic retinopathy of both eyes, with macular edema of the right eye was also on appeal. The Board granted service for the CRVO and remanded the issue of a higher rating. An issue for service connection for a vascular disorder was also remanded. The RO effectuated the Board's decision in December 2010. The RO issued a rating decision that granted service connection for the CRVO. It was not given a separate disability award but was incorporated into the Veteran's existing service-connected eye disability. The issue on appeal has been re-characterized to reflect the description of the eye disability. The issue of entitlement to a rating higher than 10 percent for service-connected nonproliferative diabetic retinopathy of both eyes, with macular edema of right eye and CRVO of the left eye associated with Diabetes Mellitus, Type II, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's vascular disorder first manifested itself many years after service and is not shown to be related to service and is not caused or aggravated by his service connection Diabetes Mellitus, Type II. CONCLUSION OF LAW The Veteran does not have a vascular disorder that is the result of disease or injury incurred in or aggravated during active military service; nor is it caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2012)), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. It also requires VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's claim for benefits was received in June 2007. The RO wrote to him in July 2007. He was provided with specific notice on how to substantiate his claim for service connection for his claimed disorder, to include as secondary to a service-connected disability. He was further advised of the information required from him to enable VA to obtain evidence on his behalf, the assistance that VA would provide to obtain evidence on his behalf, and that he should submit such evidence or provide VA with the information necessary for VA to obtain such evidence for him. He was asked to submit any medical reports that he possessed. The letter also included notice on how VA disability ratings and effective dates are determined. See Dingess, supra. The Veteran responded to the letter in July 2007. He also submitted several additional statements as well as medical evidence in support of his claim throughout the pendency of his claim. He testified as to why he believed service connection for his vascular disorder was in order. The Veteran has not disputed the contents of the VCAA notice in this case. He was afforded a meaningful opportunity to participate in the development of his claim. He identified pertinent private and VA treatment records that were obtained in the development of his claim. Thus, the Board is satisfied that the duty to notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. The Veteran's STRs were already associated with the claims folder. The Veteran identified several sources of private treatment as well as treatment by VA. The private records were obtained and associated with the claims folder. VA records of the Veteran's treatment were also obtained. He testified at a video conference hearing in September 2010. His case was remanded for additional development, to include a VA examination and opinion, in November 2010. The Board finds that the examination was adequate to allow proper adjudication of the issue on appeal. The examiner conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered a well supported opinion based on consideration of the full history of the disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that VA has satisfied its duty to notify and assist. The Veteran has not identified any other pertinent evidence, not already of record. The Board is also unaware of any such evidence. II. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury, contracted in the line of duty, incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the United States Court of Appeals for Veterans Claims (Court) or the United States Court of Appeals for the Federal Circuit (Federal Circuit), lay observation is competent. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). The law also provides that service connection may be granted for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Also, when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2012). The Veterans service treatment records (STRs) are negative for evidence of a vascular disorder in service. This includes his enlistment and separation examinations from both periods of service - June 1958 and August 1961 and December 1961 and September 1967. There are a number of clinical entries for treatment for unrelated complaints. The Veteran was assigned to an Underwater Demolition Team (UDT)/Seal Team during his second period of service. He received annual check-ups to certify his physical status from 1962-1966. No vascular disorder was identified. The Veteran submitted his initial claim for VA disability compensation benefits in May 2001. At that time he was seeking service connection for diabetes mellitus. Private treatment records from D.F. Schultz, M.D., for the period from February 1997 to May 2001, documented treatment for diabetes mellitus throughout that period. However, no vascular disorder was identified. A VA Agent Orange examination from August 2001 noted a finding of diabetes mellitus as well as claimed exposure to herbicides from the Veteran's service in Vietnam. There was no finding of a vascular disorder. The Veteran was granted service connection for Diabetes Mellitus, Type II, in July 2002. The grant of service connection was on a presumptive basis due to the Veteran's exposure to herbicides in Vietnam. The Veteran sought service connection for peripheral neuropathy of the lower extremities as secondary to his service-connected diabetes mellitus in May 2005. Private treatment records from F. E. Taylor, D.O. and T. T. Ngo, M.D., documented treatment for diabetes mellitus as well as peripheral neuropathy of the lower extremities. However, there was no evidence of any vascular disorder of the lower extremities. A VA examination from June 2007 provided a diagnosis of diabetic polyneuropathy. The examiner related the diagnosis to the Veteran's service-connected diabetes mellitus. Service connection for peripheral neuropathy of the lower extremities was granted in June 2007. The Veteran submitted his claim for service connection for a vascular disorder in June 2007. The claim was denied in May 2008. The basis for the denial was the absence of evidence of the claimed disorder. Additional evidence considered by the RO included VA treatment records from May 2005 to November 2007 as well as VA eye examination reports from 2007 and 2008 and private records from J.G. Staggs, D.O. The Veteran was referred for a VA kinesiotherapy consult in August 2008. He was identified as having varicose veins in the lower extremities. He was evaluated and fitted for compression hose. The Veteran testified in regard to his vascular disorder at his hearing in September 2010. He noted that VA had diagnosed varicose veins in his legs. He had been given Jobst stockings for treatment. He took no medication for his condition. The Veteran noted that he had a vascular problem in his eye, CRVO, that he related to his diabetes. He felt his varicose veins were related as well. The Veteran admitted that no medical person had told him there was connection. The Veteran submitted evidence after the hearing that included medical literature relating to possibly etiologies for the then nonservice-connected CRVO. He also submitted VA treatment entries dated in 2010 that provided an assessment of PVD of the eyes. However, the common use of the abbreviation is posterior vitreous detachment in regard to the eyes. The Board remanded the case for a VA examination in November 2010. The Veteran was afforded an examination in January 2011. The examiner noted that he had reviewed the claims folder. The examiner said the Veteran was found to have varicose veins when he was evaluated for bilateral knee pain. The date of onset was given as 2009. The only treatment was support stockings. The examiner noted the presence of varicose veins in the upper and lower parts of each leg. The examiner stated that varicose veins were not noted to be caused by diabetes but were a common venous disorder with risk factors that included advanced age, obesity and family history. He said that diabetes could cause complications in those that have more severe varicose veins associated with ulcer formation and subsequent impaired healing. He said the Veteran had not had any complications from his varicose veins to date and there was no aggravation by his diabetes. The Veteran's claim was re-adjudicated in April 2012. The claim remained denied and he was issued a supplemental statement of the case (SSOC) that listed the evidence added to the record since the statement of the case (SOC) was issued and the basis for the continued denial of the claim. The Veteran submitted additional medical evidence in the form of VA treatment records directly to the Board in May 2012. The Veteran waived consideration of the evidence by the agency of original jurisdiction (AOJ). This waiver was confirmed by the Veteran's representative in a submission dated in July 2012. The records related to the Veteran's service-connected eye disabilities and did not address his vascular disorder. As noted above, the Veteran's STRs are negative for evidence of complaints or treatment for his claimed vascular disorder. The absence of entries in the STRs regarding the claimed disability is not dispositive. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board has considered that lay evidence in the form of statements and testimony of the Veteran as competent to establish evidence of symptomatology where symptoms are capable of lay observation even where there is no evidence in the STRs. See Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Buchanan, supra. Further, a claimant is generally competent to introduce lay testimony of observable symptoms of disability and continuity of such symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case the Veteran clearly is able to identify varicose veins. See Barr, supra. Moreover, there is no doubt of the existence of the claimed disorder. However, he does not contend that his vascular disorder began in service. Rather, he maintains that it is a secondary disorder that is caused and/or aggravated by his service-connected diabetes mellitus. He believes that since he has a vascular disorder that involves the eyes and is service-connected, the same should be true for his lower extremities. The Veteran is not competent to relate whether his varicose veins/vascular disorder is either caused or aggravated by his service-connected diabetes mellitus. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). The VA examiner from January 2011 reviewed the evidence of record in addition to interviewing the Veteran. The examiner opined that the Veteran's varicose veins were not caused by diabetes mellitus. The examiner noted that, in some instances, diabetes mellitus can cause complications for those with more severe varicose veins associated with ulcer formation and subsequent impaired healing. However, as the Veteran had not suffered any complications from his varicose veins, the examiner stated that the Veteran's diabetes mellitus had not aggravated his varicose veins. The opinion of the examiner is afforded more probative value in that he is a medical professional that has reviewed the evidence of record. He is knowledgeable of the conditions caused by diabetes mellitus and is also knowledgeable of how diabetes mellitus can aggravate certain conditions, such as varicose veins. However, the evidence did not support such a conclusion in this case. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). ORDER Service connection for a vascular disorder is denied. REMAND As noted, the Veteran was granted service connection for his Diabetes Mellitus, Type II, in July 2002. VA treatment records identify nonproliferative diabetic retinopathy (NPDR) in 2005. In May 2006 the Veteran reported having had a retinal hemorrhage of the left eye. He related that he was seeing a private doctor for the condition. The Veteran had high resolution images of the fundus of both eyes. A VA clinic note from December 2006 said the images showed extensive macular exudation with blurred disc margins in the left eye. The entry said this represented a significant worsening of the disease since 2005. The Veteran was seen in the ophthalmology clinic in January 2007. The results of the prior imaging were noted. The entry also noted the Veteran's reporting of a blood clot in the left eye that was managed by a private doctor. This initially occurred about a year earlier. The Veteran had uncorrected visual acuity of 20/20 in the right eye and 20/400 in the left eye. The entry also reported confrontational visual fields as FT3SC in the right eye and blurry centrally but FTFC (full to finger counting) peripherally in the left eye. The pertinent diagnoses were Diabetes Mellitus, Type II with mild NPDR and history of CRVO in the left eye. The Veteran submitted a claim for an increased rating for his service-connected diabetes mellitus and his left eye (CRVO) condition in June 2007. He was afforded a VA eye examination in October 2007. The examiner noted that the Veteran had been diagnosed and treated for CRVO in the left eye beginning in 2006. The treatment had not been successful and the Veteran's had minimal to no improvement in the central vision of his left eye. The Veteran had uncorrected distance vision of 20/20 and uncorrected near vision of 20/40 in the right eye. The near vision improved to 20/20 with correction. The left eye had uncorrected distance vision of 20/400. The examiner said the visual acuity did not improve with either pinhole or manifest refraction. The Veteran's left eye near vision was 20/800 and improved to 20/400 with refraction. The examiner said the Veteran's confrontational visual fields were FTCF in both eyes. The examiner provided the following impressions: diffuse macular edema in the left eye, secondary to CRVO and possibly aggravated by NPDR. This had been resistant to treatment. The examiner said the CRVO was not directly related to the Veteran's diabetes but said that the Veteran's diabetes and hypertension and other vascular risk factors probably put him at higher risk. A second impression was Diabetes Mellitus, Type II, with moderate NPDR. Finally, he said there was increased intraocular pressure in both eyes. The Veteran underwent visual field testing in October 2007 that was reported on a Goldmann Perimeter Chart. The results were not addressed in the examination report but were added to the claims folder at a later date. VA treatment records noted continued treatment for the Veteran's left eye throughout 2007 as well as monitoring of his right eye. An addendum to the October 2007 VA examination report was provided in April 2008. The examiner did not have access to the claims folder. The prior examination report was included. The examiner noted that she had also reviewed some records available to her. She said she was asked to differentiate the degree of disabling effects of the CRVO from the Veteran's nonproliferative macular edema in the left eye. She said the Veteran's visual acuity of 20/400 in the left eye was the result of the CRVO with macular edema and not from NPDR. She said the Veteran had NPDR in both eyes and that the visual acuity of the right eye remained at 20/20. She said that the Goldmann bowl test was performed and did not show definite glaucomatous changes on the right. She said there was some mild generalized constriction superiorly and inferiorly on the right. On the left there was generalized 360 degree constriction with a central scotoma of approximately 8 degrees. The RO issued a rating decision that denied service connection for the CRVO in May 2008. At the same time, the RO included the Veteran's bilateral NPDR in his current 20 percent rating for his service-connected diabetes mellitus. This was based on a determination that the disability was noncompensable at the time. The Veteran submitted his disagreement with the denial of service connection for his CRVO and the lack of a separate rating for his NPDR. The Veteran was afforded a VA eye examination in February 2009. The Veteran's right eye uncorrected distance vision was noted to be 20/60+2/-2. His corrected distance vision was 20/40+2. The examiner expressed the Veteran's uncorrected near vision as J7 and corrected as J3. In regard to the left eye, the Veteran had uncorrected and corrected distance vision of 20/CF (count fingers) at 4 feet. His uncorrected and corrected near vision was reported as >20/800. The Veteran also underwent visual field testing with only partial results listed in the examination report. The examiner listed diagnoses of history of CRVO of the left eye with diffuse chronic macular edema status post retina laser/steroid/Avastin intraocular injections. Mild-moderate NPDR of both eyes with clinical significant macular edema (CSME) of the right eye status post retina laser x 2, STK steroid injection. Cataracts were noted in both eyes as well as refractive error/presbyopia. Finally, there was a history of ocular hypertension that was well controlled, with intraocular pressure lowering medications. The examiner stated that the Veteran's NPDR was due to his diabetes mellitus. He said the decrease in visual acuity of the right eye was more likely than not the result of CSME that was the result of diabetes mellitus. The examiner said the cataracts were age appropriate and likely as not aggravated by the Veteran's steroid injections in the left eye. The Veteran's ocular hypertension was said to not be due to his diabetes mellitus. Finally, the examiner said the Veteran's CRVO was not due to diabetes mellitus. The examiner provided an addendum to his report in March 2009. The examiner stated that the Veteran's vision field impairment was due to the CSME and that the CSME was due to the Veteran's service-connected diabetes mellitus. The examiner also said the Veteran had experienced gradual progressive blurring of his right eye, especially since receiving laser treatment in September 2008. His said this was consistent with changes in the Veteran's best corrected distance visual acuity in the right eye of 20/20 in October 2007 to 20/40+2 in February 2009. The RO granted an increased/separate 10 percent rating for bilateral diabetic retinopathy with macular edema involving the right eye in March 2009. The 10 percent rating was made effective from the date of the claim, June 11, 2007. The disability was evaluated under Diagnostic Code 6080 for a loss of visual field in the right eye. 38 C.F.R. § 4.84a (2008). In that regard, the RO reviewed the visual field test charts from the October 2007 and February 2009 examinations to determine that the Veteran had contraction to 45 degrees in October 2007 and 57 degrees in February 2009. The level of contraction met the criteria for a 10 percent rating under Diagnostic Code 6080. The Veteran continued to disagree with the disability rating assigned for his bilateral eye disability. Additional VA treatment records associated with the claims folder showed a gradual decline in the Veteran's visual acuity in the right eye and no improvement in the left eye. In an entry submitted at the time of his hearing, the Veteran's right eye visual acuity was reported as 20/70+1 in September 2010. The Board granted service connection for the Veteran's CRVO in November 2010. In so doing, the Board noted that the VA examiners of October 2007 and February 2009 said the CRVO was not caused by the Veteran's service-connected diabetes mellitus. However, the Board found the evidence to be in equipoise as to the question of whether the Veteran's CRVO was aggravated by his service-connected diabetes mellitus. The Board remanded the issue of entitlement to a higher rating for bilateral diabetic retinopathy. The Board noted that regulations used to evaluate disabilities of the eye were amended in December 2008. However, the change in regulations was for claims received on or after December 10, 2008, and was not applicable to the pending claim. The remand included instructions for interpretation of the visual field tests done in October 2007 and February 2009. On remand, the AMC effectuated the Board's grant of service connection for CRVO in December 2010. The AMC included the disability with the Veteran's existing bilateral diabetic retinopathy disability. The disability remained at the 10 percent level under Diagnostic Code 6080. There was no discussion of a rating based on visual acuity; only that the disability was to be rated under visual impairment. The rating decision went on to say that the CRVO was rated under the same criteria as the Veteran's bilateral NPDR. No increase was warranted as it would constitute pyramiding. 38 C.F.R. § 4.14. The December 2010 rating decision failed to acknowledge that the 10 percent rating from March 2009 was predicated solely on the Veteran's impairment of the field of vision for his right eye. This is clearly stated in the Reasons for Decision section of the rating decision. The March 2009 decision noted the evidence showed a decrease in visual acuity and visual field for the left eye but said it was related to the then nonservice-connected CRVO; a disability that was now service-connected. The Board cannot concur that no additional disability rating is to be considered in light of service connection for CRVO because it would constitute pyramiding. The December 2010 rating decision provides no explanation for this determination, just a conclusory statement. The rating criteria allow for bilateral visual field disabilities to be considered under Diagnostic Code 6080. More importantly, there was no explanation as to why the Veteran's disability is not evaluated under the criteria for impairment of visual acuity. As noted, the remand sought interpretation of the visual field test charts. The examiner from the VA examination of February 2009 provided an interpretation of the test from February 2009. However, no interpretation was obtained in regard to the test from October 2007. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The AMC issued a SSOC in April 2012 that applied the interpretation provided by the VA examiner. In that regard, the AMC determined that the results reflected a visual field impairment of 57 degrees for each eye based on the test from February 2009. The determination was that an increased rating was not warranted. However, the SSOC did not address the rating criteria and the fact that a 20 percent rating may be applicable where there is a bilateral visual field impairment to 60 degrees but not 45 degrees under Diagnostic Code 6080. 38 C.F.R. § 4.84a (2008). As noted, the AMC did not obtain an interpretation of the visual field test from October 2007. Thus, the rating action as to the level of disability is not complete. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A layman's review of the results from that test indicates there may be a more severe restriction of the Veteran's field of vision in both eyes based on the charted values. This fact was noted in the March 2009 rating decision when the RO said there was an impairment of 45 degrees in the right eye based on the October 2007 test. As this case involves an appeal of an initial disability rating, the question of staged ratings is for consideration from the date of the claim in June 2007. Fenderson v. West, 12 Vet. App. 119 (1999). Finally, as noted, the regulations used to evaluate disabilities of the eye were amended in December 2008. The prior remand noted that the regulations were not applicable to this case. In that regard, the prior procedures for evaluating disabilities that involved disabilities of visual acuity and visual fields was to examine the Veteran and forward the case to the Director of Compensation and Pension (C&P) Service for a determination. See 64 Fed. Reg. 25,249 (May 11, 1999)(Proposed rule change to add a paragraph (c) to §4.77 to have the AOJ rate the combination of disabilities). This discussion noted the procedure, as contained in VA's Adjudication Manual, M21-1, directed that cases involving disabilities of visual field and visual acuity be referred to the Director of C&P. This procedure was changed with the amended regulations. The changed regulations direct that the impairments of visual acuity and visual field defect are to be evaluated separately and then combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.77(c) (2012). No referral to the Director of C&P is necessary. The Veteran has not had an examination of his service-connected eye disabilities since February 2009. The VA treatment records submitted by the Veteran in May 2012 reflect a decrease in the visual acuity of his right eye and no improvement in the left eye. On remand, a new examination is required to assess his current status. The examination must include a visual field examination as well. Thereafter, the Veteran's case should be referred to the Director of C&P for assessment. Accordingly, the case is REMANDED for the following action: 1. RO should contact the Veteran and request that he identify the names, addresses and approximate dates of treatment for all health care providers, VA, private, or military (retired healthcare), who may possess additional records pertinent to his claim. The RO should attempt to obtain and associate with the claims folder any medical records identified by the Veteran that are not already of record. 2. Upon completion of the above development the Veteran should be afforded a VA examination to assess the status of his service-connected nonproliferative diabetic retinopathy of both eyes, with macular edema of right eye and central retinal vein occlusion of the left eye associated with Diabetes Mellitus, Type II. The claims folder and a copy of this remand must be provided to the examiner and reviewed as part of the examination. All indicated studies, tests and evaluations deemed necessary by the examiner should be performed. All results of any such studies, tests, or evaluations must be included in the examination report. The examination must include testing of the Veteran's visual fields with the results included with the examination report. The results must contain the degrees of visual field for each of the 8 principal meridians. The examiner is also requested to review the results of the October 2007 visual field testing and interpret the results to show the degrees for the 8 meridians from that test for each eye. 3. The RO must ensure that the medical examination report and requested interpretation of the visual field tests comply with this remand. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After undertaking any other development deemed appropriate, the RO should re-adjudicate the issue on appeal. This requires referral of the case to the Director of C&P in keeping with procedures in place prior to the amendment of the regulations in December 2008. The Veteran's disability should be evaluated for impairment of his visual acuity and visual field impairment. If the benefit sought is not granted, the Veteran and his representative should be furnished with a SSOC and afforded an opportunity to respond before the record is returned to the Board for further review. Thereafter, the case should be returned to the Board for further appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified by the RO. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ MICHAEL D. MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs