Citation Nr: 1302188 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 09-46 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for left optic neuropathy, status post tumor removal. 2. Entitlement to service connection for right eye deterioration. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from August 1973 to July 1976 and from July 1978 to February 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The case was remanded in August 2011 to obtain additional treatment records and to afford the Veteran a VA examination. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The August 2011 Remand also included the issues of service connection for headaches and a cardiac disorder characterized by heart palpitations. Following the Board's requested development, service connection for those issues were granted in an October 2012 rating decision. As the Veteran has not disagreed with the effective dates and/or disability ratings assigned to those disabilities, the Board concludes that only the issues listed on the title page remain on appeal. The Veteran has submitted new evidence in the form of a statement regarding the issues on appeal. The Veteran specifically waived his right to have the RO consider this evidence in the first instance. 38 C.F.R. § 20.1304(c) (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Left optic neuropathy, status post tumor removal, was not present during service, a malignant tumor was not manifest within a year of separation from service, and the currently diagnosed left optic neuropathy did not develop as a result of any incident during service. 2. Right eye deterioration was not present during service, a malignant tumor was not manifest within a year of separation from service, and the currently diagnosed right eye deterioration did not develop as a result of any incident during service. CONCLUSIONS OF LAW 1. Left optic neuropathy, status post tumor removal, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. Right eye deterioration was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was notified in a letters dated in December 2008 and March 2009 of what the evidence must show to establish entitlement to the benefits sought, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. They also notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), post-service medical records, Social Security Administration (SSA) records and also secured an examination in furtherance of his claims. A pertinent VA examination was obtained in October 2011 (both issues). 38 C.F.R. § 3.159(c)(4). The VA examination obtained in this case is sufficient, as the examiner conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, 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). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (1995). Certain chronic diseases (e.g., malignant tumors) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). As the evidence shows that the Veteran's left optic neuropathy, status post tumor removal, and right eye deterioration have the same etiology, the Board will address both issues together. The Veteran contends that he has left optic neuropathy, status post tumor removal, and right eye deterioration that are related to his military service. Specifically, he contends that sarcoidosis in service caused a pituitary macroadenoma or that the pituitary macroadenoma began in service. See, e.g., December 2008 and September 2009 statements. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current eye disorders resulting from a pituitary macroadenoma became manifest or otherwise originated during his period of service or within one year of service separation or are otherwise related to his military service. There is no finding that left optic neuropathy, right eye deterioration or a pituitary macroadenoma were treated or diagnosed during service. The Veteran's entrance examination in July 1973, August 1974 annual examination, July 1976 discharge examination, March 1978 examination, and December 1985 periodic examination all revealed clinically normal eyes, ophthalmoscopic system and endocrine system. Vision testing in July 1973, July 1976, March 1978 and December 1985 all revealed distant vision of 20/20 bilaterally. Although distant vision in his right eye was 20/20 in August 1974, it was 20/17 in his left eye. He had near vision of J1 bilaterally in July 1973; 20/20 bilaterally in August 1974; and J1 bilaterally in March 1978. In his August 1974 and July 1976 reports of medical examinations, he admitted having eye trouble. The Veteran did not identify what eye trouble he had in August 1974, but reported occasional bouts of nystagmus for years in July 1976. He reported not knowing whether he had a tumor, growth, cyst or cancer in August 1974. However, he answered yes to having a tumor, growth, cyst or cancer in July 1976; such record does not indicate that a pituitary macroadenoma existed. The Veteran denied eye trouble as well as having a tumor, growth, cyst or cancer in March 1978. STRs pertaining to eye treatment include a record dated in September 1974 when the Veteran complained of having a bump under his left eyelid; no diagnosis of a tumor was made. He complained of blurry vision in July 1976 and was shown to have vision of 20/90 both distant and near bilaterally. He was prescribed eyeglasses that same month. There is no indication in any of his STRs that he had left optic neuropathy, right eye deterioration or a pituitary macroadenoma. He did not make complaints of symptoms associated with a pituitary macroadenoma. The Veteran's contemporaneous service records fail to show that the onset of any left optic neuropathy, right eye deterioration or a pituitary macroadenoma occurred during service. In this case, an opinion from a VA examiner was obtained in October 2011. Following examination, the Veteran was diagnosed with a pituitary macroadenoma and sensory exotropia. The Veteran reported having blurred vision and difficulty reading in service and that although he was prescribed glasses, he did not have resolution of his complaints. After reviewing the claims file and computerized VA treatment records, the examiner could not give an opinion as to whether the Veteran's visual complaints in service in the 1980s were related to the pituitary macroadenoma. The examiner noted that there was no adequate examination documentation that described the appearance of optic nerves and there was no visual field testing performed. Pituitary tumors were very slow growing typically and could take many years to be found. Vision complaints were typically vague at first because central visual acuity was not affected initially. Visual field testing could often times show the field loss that occurred with the tumors. Pallor of the optic nerves was a late finding as well. If complaints of vision were present and the patient continued to have visual complaints even with 20/20 vision, then visual field defect testing could be done to determine if there was a field defect. There was no evidence of those tests in the service records. An MRI would have shown the tumor if present, but no MRIs were performed for the repeated headache complaints. In 2006, eye examination documented optic atrophy of the left eye, but the Veteran was lost to follow-up and the ordered visual field testing did not occur until 2008. Without appropriate tests or examination information, the examiner could not form an opinion without resorting to mere speculation. The current visual disability in both eyes was directly related to the pituitary macroadenoma and the resultant compression and atrophy of the optic nerves. The Board finds that the totality of the evidence fails to show that the onset of any current pituitary macroadenoma or vision disorder occurred during the Veteran's service. The pertinent medical evidence of record fails to show opinions other than that from the October 2011 examiner. Although the Veteran reported in a December 2008 statement that his doctor told him that the pituitary macroadenoma was slow growing and had been growing for the past 15 to 20 years, the Veteran's pertinent treatment records fail to show such opinion. The VA examiner's opinion supports the Veteran's assertion that pituitary macroadenomas are slow growing. However, as discussed above, the examiner was unable to provide an opinion linking the Veteran's pituitary macroadenoma to his military service. There is also no medical evidence of the manifestation of a pituitary macroadenoma within a year of separation of service. The earliest medical record demonstrating the presence of the tumor is an MRI in January 2008 that indicated a degenerated pituitary macroadenoma. This was over twenty years after separation from service. Although the Veteran complained of poor vision in his left eye in a September 2006 VA treatment record, as noted by the October 2011 examiner, no follow-up was done to confirm the presence of the macroadenoma until 2008. No medical professional has provided any opinion indicating that a malignant tumor was manifest to a degree of 10 percent or more within one year from the Veteran's discharge from service. As explained by the October 2011 examiner, visual field testing can show field loss that occurs with tumors while an MRI will show the tumor. The Veteran's post-service treatment records do not include visual field testing or an MRI within one year of his discharge from service that could have shown the existence of a pituitary macroadenoma. The pertinent medical evidence that has been presented includes numerous records showing current left optic neuropathy and right eye deterioration. However, these records do not contain medical opinions relating any currently diagnosed visual disorder to the Veteran's military service. The evidence also does not contain any opinions relating the Veteran's pituitary macroadenoma to his military service. The probative medical evidence simply fails to adequately establish any nexus between a current visual disorder and the Veteran's periods of service. Without evidence of an in-service event, injury, or disease to the Veteran's pituitary gland or eyes or competent evidence of an association between a visual disorder and his active duty, service connection for a left eye neuropathy, status post tumor removal, and right eye deterioration is not warranted. In reaching the conclusion that the Veteran's current eye disorders are not related to his service, the Board has considered the Veteran's assertion that the in-service sarcoidosis caused the later diagnosis pituitary macroadenoma. The Veteran's STRs do reveal numerous diagnoses of sarcoidosis. However, the pertinent medical evidence of record fails to show that the in-service sarcoidosis caused the pituitary macroadenoma. No medical professional has provided any opinion as to that effect. The Veteran provided a printout indicating medical research that sarcoidosis can cause tumors; however, this printout does not establish that the Veteran's sarcoidosis caused his pituitary macroadenoma. The Veteran's treatment records pertaining to the pituitary macroadenoma do not suggest that it was caused by sarcoidosis. Although the Veteran did have sarcoidosis in service, there is no probative evidence to suggest that the pituitary macroadenoma was caused by sarcoidosis. The Board acknowledges the Veteran's argument that since it is unclear whether the tumor existed during service, service connection is warranted. See October 2012 statement. However, VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). After reviewing all of the evidence, to include the Veteran's statements as well as his STRs and treatment records, the October 2011 examiner was unable to opine that it was at least as likely as not that the Veteran's pituitary macroadenoma began during service. As discussed above, no medical professional has provided any opinion as to that effect and the Board is not free to substitute its medical judgment. Thus, while there is the possibility that a pituitary macroadenoma might have begun in service, service connection cannot be granted on speculation. The Veteran has expressed his belief that he has left optic neuropathy, status post tumor removal, and right eye deterioration that are related to his service, but there is no evidence of record showing that he has the specialized medical education, training, and experience necessary to render a competent medical opinion as to etiology of a disability. Espiritu, 2 Vet. App. 492; 38 C.F.R. § 3.159(a)(1). His own assertions as to etiology have no probative value. Without evidence of the onset of left optic neuropathy, right eye deterioration or a pituitary macroadenoma disorder in service or competent evidence of an association between a vision disorder and the Veteran's active duty, service connection for left optic neuropathy, status post tumor removal, and right eye deterioration is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claims for left optic neuropathy, status post tumor removal, and right eye deterioration. As the preponderance of the evidence is against these issues, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for left optic neuropathy, status post tumor removal, and right eye deterioration is denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2012). ORDER Entitlement to service connection for left optic neuropathy, status post tumor removal, is denied. Entitlement to service connection for right eye deterioration is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs