Citation Nr: 1306020 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 09-36 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of traumatic brain injury (TBI). 2. Entitlement to service connection for an eye disability. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at an October 2010 hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the claims file. In previous decisions, the Veteran's claim for an eye disability was captioned and evaluated as one of entitlement to service connection for right superior quadrantanopsia. However, because there is evidence that other eye conditions diagnosed during the pendency of the appeal may be related to active duty, the Board has re-captioned the Veteran's claim in order to accurately reflect this evidence. See Brokowski v. Shinseki, 23 Vet App 79 (2009), citing Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). A July 2011 Board decision remanded the claim of entitlement to service connection for residuals of TBI and denied entitlement to service connection for right superior quadrantanopsia. In pertinent part, the Board's remand directed that the RO obtain any additional service treatment records reflecting treatment for residuals of a shell fragment wound to the forehead; any additional VA medical records pertinent to treatment for residuals of TBI from the VA Medical Center (VAMC) in Martinsburg, West Virginia; any outstanding, pertinent medical records from the Lyons VAMC, East Orange VAMC, Tampa VAMC, and West Palm Beach VAMC dated from 1998 to the present; and any records from the Social Security Administration (SSA) pertinent to the Veteran's claim and/or award of SSA disability benefits. The record demonstrates additional VA medical records were obtained from the Martinsburg VAMC, Tampa VAMC, and West Palm Beach VAMC. A September 2011 letter indicates the New Jersey VA Health Care System, which includes the Lyons and East Orange facilities, was unable to locate any records pertaining to treatment for residuals of TBI. The claims file also includes records received from SSA pertaining to the Veteran's award of disability benefits. Additionally, the Board directed that the RO contact the examiner who conducted a June 2009 VA examination and obtain an addendum medical opinion as to the etiology of any current TBI residuals (if diagnosed) based upon the entire evidence of record. In October 2011, an addendum opinion was provided by the examiner who conducted the June 2009 VA examination. Accordingly, the Board finds that there has been substantial compliance with the directives of the July 2011 remand, and therefore, an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). With respect to the issue of entitlement to service connection for right superior quadrantanopsia, the Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). Pursuant to an April 2012 Order granting a Joint Motion for an Order Partially Vacating and Amending the Board Decision (Joint Motion), the Veteran's appeal concerning this issue was remanded to the Board. In September 2012, the Veteran submitted additional evidence directly to the Board concerning the issue of entitlement to service connection for residuals of TBI. As the Veteran had previously submitted a waiver of initial RO consideration of any evidence submitted subsequent to certification of the appeal, this evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The issue of entitlement to service connection for an eye disability, to include right superior quadrantanopsia and glaucoma, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDING OF FACT The competent evidence of record does not demonstrate that the Veteran has any currently diagnosed residuals of TBI incurred in active duty. CONCLUSION OF LAW The criteria for service connection for residuals of TBI have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 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 (2012). The record shows that letters dated in October 2007, December 2007, and January 2008 satisfied the duty to notify provisions; the December 2007 letter also notified the Veteran of regulations pertinent to the establishment of an effective date and disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also finds that the duty to assist the Veteran has been satisfied in this case. The record includes service treatment records, VA examination reports, VA treatment records, private treatment records, and lay evidence. As noted above, the RO fulfilled the directives of the Board remand with respect to obtaining any outstanding, pertinent service treatment records, VA treatment records, and records pertaining to the Veteran's SSA award. The Veteran was also afforded VA examinations in May 2008 and June 2009 in conjunction with his service connection claim for residuals of TBI, and an addendum opinion was obtained in October 2011. In May 2008 and June 2009, the VA examiners reviewed the Veteran's relevant medical history, to include his documented in-service injury and his lay testimony regarding his symptoms during and since separation from service, completed physical examinations and other appropriate testing, and provided opinions as to the clinical findings involving residuals of the in-service injury. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds the examinations to be sufficient and adequate for purposes of determining service connection. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the Veteran was assisted at the hearing by an accredited representative from the American Legion. The representative asked the Veteran specific questions regarding his in-service injury and his symptoms during and following separation from service. The VLJ noted the Veteran's specific statements regarding his treatment for his symptoms and indicated he would seek to obtain any other pertinent documentary evidence not currently associated with the claims folder that might substantiate the claim. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) . There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The Veteran and his representative assert that he has residuals of a TBI incurred in active duty. He reports that during service, he was wounded in an ambush by an enemy grenade, a piece of which hit him directly in the forehead. The Veteran contends that the shrapnel lodged in his brain and was never removed. The Veteran states that he lost consciousness and was placed in a body bag as he was thought to be dead. The Veteran contends that he has experienced memory loss, severe headaches, nausea, dizziness, sensitivity to light, and vision problems as the result of the in-service injury. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A March 1968 service treatment record demonstrates a diagnosis of wound, penetrating, due to fragments, forehead, no artery or nerve involvement. The record notes the Veteran was injured by a grenade and awarded the Purple Heart. The operations and special therapeutic procedures were listed as suture of lacerations, local anesthesia, Xylocaine. There was no intracranial penetration or loss of consciousness. There was a metal fragment in the anterior frontal sinus, and the forehead wound was sutured. Because of the Veteran's history of previous rheumatic fever, he was admitted for five days of parental therapy. It was noted that the wound healed well, and the Veteran was to be given light duty for two weeks, which did not require wearing a helmet. An October 1968 service treatment record indicates the Veteran had sustained a fragment wound to the forehead six months ago and since that time had been bothered by head pain. An additional October 1968 service treatment record notes a fragment in the left frontal sinus anterior wall penetrating into the sinus cavity. There was no osteomyelitis. The Veteran reported continued pain and discomfort over the bridge of his nose. X-ray examination confirmed a two to three millimeter fragment at the site of the discomfort. It was noted that the Veteran should have the fragment removed in one month. A January 1969 service treatment record indicates the Veteran had returned from the Republic of Vietnam and was complaining of pain from shrapnel in the left frontal sinus area. X-ray examination confirmed a fragment. However, a February 1969 service treatment record shows the Veteran was not having any difficulty, was going to wait on surgery, and would return if symptomatic. A February 1996 VA treatment record indicates a diagnosis of cognitive disorder, mild, possibly secondary to head trauma. An April 1996 VA treatment record shows an impression of cognitive disorder secondary to head trauma. A June 2000 discharge summary from the Martinsburg VAMC indicates the Veteran was admitted to the facility's Domiciliary Mainstream Program in November 1999. The Veteran reported sustaining a traumatic injury with shrapnel through the left skull in 1968. He currently complained of impaired memory and speech comprehension, as well as periodic black-out episodes. The record indicates that he underwent neuropsychological testing in June 1999 and was found to have moderate to severe loss of cognitive abilities and significant deficit of memory in most areas except for septral organization and working memory. It was also noted that the Veteran had severe posttraumatic stress disorder (PTSD) and depression. The Veteran completed the Mainstream Program and exhibited marked improvement in many areas of his cognitive therapy, particularly memory and problem solving. The diagnoses were TBI, depression, and PTSD. A September 2007 VA treatment record demonstrates a diagnosis of rule out cognitive disorder due to TBI. A November 2007 X-ray examination of the Veteran's skull showed no indication of metallic foreign bodies over the calvarium, and a December 2007 magnetic resonance imaging scan (MRI) revealed no acute intracranial pathology and scattered FLAIR hyperintensities within the white matter, likely the sequela chronic small vessel ischemic change. A December 2007 computed tomography (CT) scan of the brain without contrast reflected no acute intracranial pathology and minimal periventricular and subcortical white matter hypodensity compatible with minimal chronic small vessel ischemic disease. A February 2008 VA treatment record demonstrates an impression of posttraumatic brain disorder. In May 2008, the Veteran underwent VA examination in connection with his claim. The Veteran reported a history of headaches, balance problems, visual problems, cognitive problems, dizziness, tinnitus, pain, sexual dysfunction, and psychiatric symptoms. The VA examiner reviewed the Veteran's claims file and performed a physical examination of the Veteran. The VA examiner found there was no evidence to support a diagnosis of TBI. The VA examiner explained that by definition, TBI requires a history of head injury with significant loss of consciousness (hours to days), which was then followed by days of confusion that gradually merged into clear cognitive, memory, and behavioral difficulties. The symptoms then improved over the course of six to 12 months at which time they stabilized. Because the Veteran did not meet the criteria of TBI, the VA examiner found there were no residuals of TBI. A June 2008 VA treatment record observed that the Veteran was unable to tandem gait and the VA physician reported that it was most likely secondary to TBI. The impression included posttraumatic brain disorder. A September 2008 VA treatment record reflects a diagnosis of mood disorder due to TBI. On VA examination in June 2009, the Veteran reported that he got injured during a combat operation in March 1968 due to a grenade explosion. According to the Veteran, he became very light sensitive and developed headaches following the injury. He reported that he was admitted to the Martinsburg VAMC TBI program for eight months in 1999 and was told that he had lost 20 years of long-term memory due to his TBI. The Veteran stated that he was told there was a mass formed around the remaining fragment that had separated the nutrient in his brain. He reported that he eventually reconnected his brain function. It was noted that the Veteran attended college after service and worked as an architectural engineer and commercial building designer for 25 years. He asserted that he was very good at his job until he suffered a panic attack in 1999. The Veteran reported a history of headaches, balance problems, pain, sleep disturbance, and psychiatric symptoms. There was objective evidence on testing of severe impairment of memory, attention, concentration, and executive functions resulting in severe functional impairment. The VA examiner found the Veteran had mildly impaired judgment; three or more subjective symptoms that mildly interfered with work; one or more neurobehavioral effects that did not interfere with workplace or social interaction; and the ability to communicate by spoken and written language. The VA examiner commented that the Veteran's impairment was not due to TBI but was the result of severe test anxiety. After reviewing the Veteran's claims file and clinical findings, the VA examiner found the Veteran did not present a TBI profile. The VA examiner noted there was no evidence of shrapnel in the Veteran's head and that he had a successful career for over 20 years following the injury. The VA examiner found the Veteran was extremely anxious but cooperative and appeared to put forth an honest effort to perform. However, his anxiety was so high that it negated the results of the test. Per the VA examiner, neurological testing revealed that the Veteran's estimated premorbid functioning was within the average range. However, the Veteran's language abilities were severely impaired by anxiety, which did not match his premorbid functioning level. The Veteran's attention and ability to concentrate indicated severe impairment from anxiety as well. His memory and ability to recall and manipulate information was severely impaired by anxiety, while his ability to retrieve information remained intact. Additionally, the findings indicated that the Veteran was unable to recognize or recall information from memory when asked specific questions to help him remember the elements of the previously presented stories. Executive functioning remained in the low average range and was less impaired because it was a visual task. The VA examiner discerned that the Veteran's anxiety had become apparent with the use of computers and he was unable to adapt. The VA examiner reported that the Veteran's severe test anxiety did not allow the test to determine his true abilities. With respect to a diagnosis, the VA examiner found the Veteran did not incur a TBI during service. The VA examiner diagnosed posttraumatic headaches, tension type, and found there was no supportive evidence of TBI residuals. As a result, the VA examiner opined that it was less likely as not that the Veteran had TBI residuals due to his shrapnel wound in Vietnam. The VA examiner noted the Veteran's statements regarding his in-service injury; however, the VA examiner found they were inconsistent with his service treatment records that clearly documented no intracranial penetration or loss of consciousness. Further, the service treatment records demonstrate the Veteran was kept in the hospital for five days to receive parental therapy for his known rheumatic fever and not for a TBI. The VA examiner found it significant that the Veteran had attended college and worked as a successful architectural engineer and commercial building designer for 25 years. The VA examiner opined that these experiences did not reflect a typical TBI pattern. An October 2010 VA treatment record reflects a provisional diagnosis of TBI and a positive screening for TBI. The record notes the Veteran suffered a grenade injury in March 1968 with shrapnel to the forehead. A March 2011 VA treatment record indicates bitemporal hypometabolism was related to TBI but might have been a combination of PTSD, leukoaraiosis, and even early frontotemporal dementia subtype. An October 2011 MRI of the brain without contrast reveals no acute findings of the brain and no change since 2007. In October 2011, the VA examiner who performed the June 2009 VA examination provided an addendum opinion as to whether it was at least as likely as not that the residuals of any TBI are related to service. The VA examiner reviewed the Veteran's claims file and determined that the available service treatment records did not support the finding that the Veteran suffered true traumatic brain injury. Although there was evidence of a grenade fragment injury to the forehead in March 1968, there was no intracranial penetration or loss of consciousness. The wound was sutured under local anesthesia, Xylocaine. The VA examiner noted the Veteran was kept in the hospital after the injury for five days not due to a brain injury but to receive parental therapy for his known rheumatic fever. The VA examiner found it significant that following service, the Veteran reported attending college and working as a successful architecture engineer and commercial building designer for more than 25 years. He also asserted he was very gifted at his occupation. The VA examiner found these experiences did not reflect a typical TBI pattern or residuals profile. Therefore, the VA examiner found it was less likely as not (less than 50 percent probability) that any current TBI residuals were related to active duty. The VA examiner also noted that the Veteran had a history of noticeable mental health disabilities per VA medical records. Further, the VA examiner found it significant that the Veteran had numerous brain diagnostic tests, including a CT scan and MRI, which all failed to show any overt TBI abnormalities, except some white matter change likely due to sequela chronic small vessel ischemic change and not related to TBI. A May 2012 VA treatment record reflects a clinical assessment of cognitive impairment related to PTSD and leukoaraiosis. The Veteran's service treatment records demonstrate the Veteran incurred an in-service injury for the purpose of service connection. However, the competent and probative evidence of record does not support the findings that the Veteran incurred a TBI during active duty and does not relate any current symptoms to an in-service TBI. The Board acknowledges that multiple VA treatment records indicate diagnoses and impressions of TBI. The June 2000 discharge summary diagnosed TBI, while VA treatment records dated in February 2008 and June 2008 reflect impressions of posttraumatic brain disorder. In addition, an October 2010 VA treatment record reveals a provisional diagnosis of TBI and a positive screening for TBI. However, the Board affords this evidence less probative value than the May 2008, June 2009, and October 2011 VA examinations and opinions. First, the Board notes that it is not clear whether the VA physicians providing the June 2000, February 2008, June 2008, and October 2010 diagnoses reviewed the Veteran's claims file. Conversely, the evidence of record demonstrates that the VA examiners reviewed the Veteran's claims file, to include his service treatment records and testing results, prior to providing the opinions and cited the record as a basis for the opinions. The Board also acknowledges that when contemplating a medical opinion, the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the claimant's past medical history." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, it appears the VA physicians were basing their diagnoses in June 2000, February 2008, June 2008, and October 2010 on the medical history as reported by the Veteran. However, the Veteran's service treatment records do not corroborate the Veteran's description of his in-service injury and treatment thereof. In fact, the October 2011 VA examiner specifically found that the Veteran's reports were inconsistent with his service treatment records. Here, the service treatment records clearly documented that there was no intracranial penetration or loss of consciousness and also indicated that he was kept in the hospital for five days not for treatment of the forehead injury but to receive parental therapy for rheumatic fever. Additionally, the VA physicians did not provide a basis for the diagnoses other than the Veteran's reported history of an in-service TBI, and as a result, the Board finds the diagnoses carry less probative weight in comparison to the May 2008 and June 2009 VA examiners' opinions. In this respect, the May 2008 VA examiner explained that TBI requires a history of head injury with significant loss of consciousness followed by days of confusion, which gradually merged into clear cognitive, memory, and behavioral difficulties. The symptoms then improved over the course of six to 12 months at which time they stabilized. Because the evidence of record did not demonstrate that the Veteran met the criteria of TBI, the VA examiner found there were no residuals of TBI. Similarly, the June 2009 VA examiner opined that the Veteran's experiences did not reflect a typical TBI pattern. In this regard, the VA examiner highlighted the Veteran's education and occupational success following service. Although the VA examiner did not have the ability to review any records dated after October 2011, the only medical record pertinent to the Veteran's claim is the May 2012 VA treatment record, which reflects a clinical assessment of cognitive impairment related to PTSD and leukoaraiosis. As there is no further evidence supporting a diagnosis or residuals of TBI following the October 2011 VA examination, the Board finds the opinion adequate for purposes of determining service connection. Here, the pertinent evidence of record, to include the Veteran's service treatment records, test results, and clinical findings, do not demonstrate that the Veteran has any current residuals of TBI related to active duty. The Board acknowledges that the Veteran is competent to testify to events that he actually experienced or witnessed, such as incurring a head injury in service. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). However, while the Veteran's statements have been deemed competent evidence, the Board must also determine whether such evidence is credible. Id. In this respect, the Veteran's statements regarding the severity of the in-service injury are contradicted by his service treatment records. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that credibility may be impeached by a showing of inconsistent statements or consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). As a result, the Board finds the Veteran's lay testimony not credible and therefore not competent evidence regarding the incurrence of a TBI during active duty. Furthermore, although the Veteran and his representative argue that he has residuals of an in-service TBI, it is well established that a layperson without medical training is not qualified to render medical opinions regarding the etiology of disorders and disabilities. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, as the diagnosis and residuals of TBI are not simple questions that can be determined based on mere personal observation by a lay person, the Veteran's lay testimony is not competent to establish medical etiology or nexus. See Jandreau, 492 F.3d at 1376-77; see also Davidson, 581 F.3d at 1316. The question of whether the Veteran incurred a TBI in service and currently has residuals of TBI does not lie within the range of common experience or common knowledge. It is not shown that the Veteran or his representative is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to a diagnosis or residuals of TBI. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for residuals of TBI. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56 (1990). ORDER Entitlement to service connection for residuals of TBI is denied. REMAND The Veteran asserts that he has an eye disability as the result of a head injury incurred during active duty. A March 1968 service treatment record demonstrates a diagnosis of wound, penetrating, due to fragments, forehead, no artery or nerve involvement. The record notes the Veteran was injured by a grenade and awarded the Purple Heart. The Veteran underwent VA examinations in May 2008 and June 2009 in conjunction with his service connection claim. On VA examination in May 2008, the Veteran gave a history of a shell fragment wound to the left forehead and subsequent development of right superior homonymous quadrantanopsia. He also complained of light sensitivity. Upon physical examination, the VA examiner diagnosed severe light sensitivity more likely than not due to TBI and right superior quadrantanopsia more likely than not due to TBI. The VA examiner also noted that the visual field defects may include the right superior quadrantanopsia and possibly glaucoma as well as an enlarged cup to disc ratio, more so in the right eye. Other diagnoses included glaucoma suspect based on cup to disc ratio bilaterally and early nuclear sclerotic cataract. The VA examiner did not discuss the Veteran's medical records and did not provide a rationale for the opinion. The June 2009 VA examiner reviewed the Veteran's claims file, to include his service treatment records and his medical history. After physical examination, the VA examiner provided diagnoses of visual field defect bilaterally - constricted III4e isopter; superior/superior temporal OD and paracentral scotoma OD; superior/superior nasal OD and paracentral scotoma OD; visual field defect bilaterally, not consistent with right superior quadrantanopsia; and glaucoma suspect bilaterally. Based on the evaluation, to include Goldmann Visual Field testing, the VA examiner found the Veteran did not display a right superior (homonymous) quadrantanopsia. The Veteran did show some constriction of his superior and superior temporal field OD and his superior and superior nasal field OS, along with a superior paracentral scotoma OU. Consequently, the VA examiner opined that he was unable to resolve whether the findings were due to the Veteran's active military service or if they were due to an ocular condition such as glaucoma (for which the Veteran was not currently diagnosed) without resorting to speculation. The VA examiner found it was worth noting that the May 2008 VA examiner also thought the Veteran was a glaucoma suspect. As the Veteran was scheduled for a routine appointment in the near future for further evaluation of his symptoms, the VA examiner recommended deferring a rating decision until the exact etiology of visual field changes could be determined. Here, the Board finds remand is warranted to obtain an additional examination and opinion as to whether the Veteran has a current eye disability related to active duty. 38 U.S.C.A. §§ 5103A, 5107(a) (West 2002); 38 C.F.R. § 3.159 (2012). Although VA may not order additional development for the sole purpose of obtaining evidence unfavorable to a claimant, see Mariano v. Principi, 17 Vet. App. 305, 312 (2003), VA has discretion to determine when additional information is needed to adjudicate a claim. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (stating that VA has discretion to schedule a Veteran for a medical examination where it deems an examination necessary to make a determination on the Veteran's claim); Shoffner v. Principi, 16 Vet. App. 208, 213 (2002) (holding that VA has discretion to decide when additional development is necessary). Here, the Board finds the May 2008 VA examiner's opinion is inadequate as the VA examiner provided no rationale for the opinion that the Veteran's severe light sensitivity and right superior quadrantanopsia were more likely than not due to TBI. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, the Board finds the June 2009 VA examination is inadequate for purposes of determining service connection for an eye disability. The evidence demonstrates that the June 2009 VA examiner based the opinion, in part, on the lack of a current diagnosis of right superior (homonymous) quadrantanopsia. However, the May 2008 VA examiner diagnosed right superior quadrantanopsia. Therefore, the record demonstrates a current disability during the pendency of the appeal for the purpose of service connection, and the VA examiner must address whether right superior quadrantanopsia is causally related to active duty, regardless of whether a current examination demonstrates the disability for VA rating purposes. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that a current disability exists if the diagnosed disability is present at the time the claim is filed or during the pendency of the claim, even if the disability resolves prior to adjudication). Further, the June 2008 VA examiner stated that he could not resolve whether the Veteran's current conditions were due to his active military service or an ocular condition without resorting to speculation. In this respect, the Court has held that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. Jones v. Shinseki, 23, Vet. App. 382, 389-90 (2010) (noting that the phrase, "without resort to mere speculation," must not become a mantra that short circuits the careful consideration to which each claimant's case is entitled and holding that, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Goss v. Brown, 9 Vet. App. 109, 114 (1996. Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or a remote possibility. See 38 C.F.R. § 3.102 (2012). Therefore, the Board finds the June 2009 VA examiner's opinion inadequate and an additional examination is necessary for the purpose of determining service connection. Finally, as the evidence of record indicates that other eye conditions may be related to active duty, the Board finds the VA examiner should address the etiology of any eye disability diagnosed during the pendency of the appeal, to include right superior quadrantanopsia. For these reasons, and in accordance with the April 2012 Joint Motion, the Board finds that the May 2008 and June 2009 VA examinations are inadequate for adjudication purposes. "Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided." Barr, 21 Vet. App. at 311. As such, in order to satisfy VA's duty to assist, the Board finds that a remand is warranted in order to afford the Veteran an additional VA examination with respect to the issue of entitlement to service connection for an eye disability. 38 U.S.C.A. §§ 5103A, 5107(a); 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA eye examination for the purpose of ascertaining the nature and etiology of any eye disability. The claims file should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. Based on the physical examination and review of the claims file, to include the Veteran's service treatment records, private treatment records, and Veteran's lay testimony, the examiner should give an opinion as to whether it is at least as likely as not (50 percent probability or more) that any diagnosed eye disability is related to service, to include any head injury sustained therein. In formulating the opinion, the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The VA examiner is reminded that regardless of whether the VA examination demonstrates a current eye disability, the assessment must include consideration of any eye disability diagnosed during the pendency of the appeal, to include the findings detailed in the May 2008 VA eye examination. A complete rationale should be provided for any opinion or conclusion expressed. 2. Then, readjudicate the claim of entitlement to service connection for an eye disability. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative must be provided with a Supplemental Statement of the Case. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. The Veteran 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 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs