Citation Nr: 1308965 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 08-29 965A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected disability. 2. Entitlement to service connection for herniated nucleus pulposus, to include on a secondary basis. 3. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 4. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity. 5. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity. 6. Entitlement to an initial evaluation in excess of 10 percent for glaucoma of the left eye. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The Veteran served on active duty from August 1961 to January 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for peripheral neuropathy of each lower extremity and for glaucoma, and denied the Veteran's claims for service connection for hypertension and herniated nucleus pulposus of the lumbar spine, and the claim for an increased rating for PTSD. The Veteran disagreed with the denials of service connection and with the evaluations assigned for his service-connected disabilities. During the hearing before the undersigned in September 2012, the Veteran withdrew his claim for an increased rating for diabetes mellitus. This decision, accordingly, is limited to the issues set forth on the preceding page. The issue of service connection for hypertension, to include as due to service-connected disability, 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. FINDINGS OF FACT 1. Service connection is in effect for, among other disabilities, residuals of a shrapnel wound of the right thigh, evaluated as 10 percent disabling. 2. The Veteran's shrapnel wound contributed to the development of herniated nucleus pulposus of the lumbar spine. 3. The Veteran's PTSD is manifested by sleep impairment, infrequent suicidal ideation and mood disturbance and resulted in reduced reliability. Deficiencies in most areas are not demonstrated. 4. Peripheral neuropathy of the left lower extremity is manifested by decreased sensation, and is not more than moderate in severity. 5. Peripheral neuropathy of the right lower extremity is manifested by decreased sensation, and is not more than moderate in severity. 6. The Veteran's corrected visual acuity is 20/40 or better in each eye. CONCLUSIONS OF LAW 1. Herniated nucleus pulposus of the lumbar spine is proximately due to or the result of a service-connected disease of injury. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.310(a) (2012). 2. The criteria for an evaluation of 50 percent, but not greater, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8723 (2012). 4. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8725 (2012). 5. The criteria for an initial evaluation in excess of 10 percent for glaucoma of the left eye have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.84a, Diagnostic Code 6013 (as in effect prior to December 10, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). The duties to notify and assist were met in this case. Notice was provided in January, May and October 2005 letters. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, private and VA medical records, VA examination reports, a statement from the Veteran's spouse and the Veteran's testimony at a hearing before the undersigned. VA clinical examinations with respect to the increased rating claims have been obtained. 38 C.F.R. § 3.159(c) (4). The Board finds that the VA clinical examinations obtained in this case are more than adequate, as they are predicated on a full reading of the medical records in the Veteran's claims file. As appropriate, clinical findings pertinent to the schedular criteria for rating the disabilities at issue were obtained. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board acknowledges the Veteran has not been afforded a VA medical examination to obtain an opinion regarding the etiology of the Veteran's low back disability. In light of the full grant of this claim, the Board finds that an examination is not necessary. Analysis The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. Service connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Allen v. Brown, 7 Vet. App. 439 (1995). VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity as well as any increase in severity. The Veteran has been granted service connection for PTSD, evaluated by this determination as 50 percent disabling; diabetes mellitus with erectile dysfunction, evaluated as 20 percent disabling; residuals of a shrapnel wound of the right thigh, evaluated as 10 percent disabling; glaucoma of the left eye, evaluated as 10 percent disabling; peripheral neuropathy of the left lower extremity, evaluated as 10 percent disabling; and for peripheral neuropathy of the right lower extremity, evaluated as 10 percent disabling. In a statement dated February 1991, a private physician noted the Veteran complained of "dragging" of the right foot. It was indicted the Veteran had received a shrapnel injury to the right distal anterior thigh with muscle injury and atrophy. The examiner noted the Veteran had muscle loss in that area. VA examinations in March 1992, April 2004 and October 2011 show the Veteran's gait was characterized as normal. Private medical records disclose the Veteran was seen in April 2004 for back pain for six weeks. Magnetic resonance imaging of the lumbar spine that month revealed disc protrusion with posterior displacement of the L5-S1 nerve root. In a statement dated November 2004, R.W.P., M.D., related the Veteran had received shrapnel wounds to the right leg in service. He stated the Veteran had experienced chronic pain and some abnormal gait as a result of the injury. He commented that due to the abnormal gait, the Veteran had put added stress to his lumbar spine area. He noted the Veteran had recently sustained a herniated disc in the lumbar spine with radicular pain in his left leg. Dr. P. concluded that the shrapnel injury to the Veteran's leg, causing abnormal gait, more than likely caused extra stress to the spine and contributed to the herniated disc. Dr. P. wrote another, virtually identical letter the same day, except he stated the shrapnel injury could have caused extra stress to the spine and contributed to the herniated disc. A VA examination in September 2011 showed leg length from the anterior superior iliac spine to the medial malleolus was 90 centimeters on the right and 92 centimeters on the left. The diagnosis was intervertebral disc syndrome. The Board acknowledges that the VA examinations failed to demonstrate the presence of a limp. However, the notation by a private physician in February 1991 that the Veteran reported dragging of his feet, and the fact the recent VA examination demonstrated a leg length discrepancy, suggest the possibility the Veteran did, in fact, have an abnormal gait. As noted above, Dr. P. indicated the Veteran did have an abnormal gait which was a factor in the Veteran's herniated disc. There is no medical opinion to the contrary. Thus, resolving all reasonable doubt in the Veteran's favor, service connection for herniated nucleus pulposus of the lumbar spine is warranted. II. Increased rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App 505 (2007). A. PTSD The Board acknowledges that a claimant may experience multiple degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. A 100 percent evaluation is warranted for PTSD with total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent evaluation is warranted if there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent evidence is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. One factor which may be considered is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep job), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See DSM-IV. The Board is cognizant that a GAF score is not determinative by itself. On VA psychiatric examination in May 2005, the Veteran reported he spent much time alone and avoided people as much as possible. He was employed, but described his relationships with his supervisor and co-workers as fair. On mental status evaluation, the Veteran's orientation was within normal limits. His appearance, behavior and hygiene were appropriate. His affect was normal. Panic attacks were absent. There were no delusions or hallucinations. He had an obsessional ritual which involved constantly checking the keys at work. His thought processes were appropriate. His judgment was not impaired. The Veteran's memory was within normal limits. There was no suicidal or homicidal ideation. The diagnosis was PTSD, and a Global Assessment of Functioning score of 70 was assigned. VA outpatient treatment records disclose the Veteran was seen in December 2006 and reported he experienced nightmares, insomnia, and night sweats. He asserted he did not like to be in crowds. He alleged his symptoms had increased since September 2001. He claimed he felt guilty and that he had panic attacks. He maintained he did not have a lot of friends. A mental status evaluation revealed he had no hallucinations or illusions. There were no obsessions. It was reported he had experienced suicidal ideation, but had no attempts. His insight and judgment were good. His grooming was appropriate. The assessments were PTSD and major depression. The Veteran was again afforded a psychiatric examination by the VA in September 2007. He stated he was working, that the job was stressful, but he did not want to retire on the advice of his doctors so that he could keep busy and not focus on his own problems. He reported persistent, recurrent and distressing dreams of his stressor. He said he can never sleep for more than two hours at a time, and that he was always alert. He claimed he had flashbacks three or four times a week, particularly at night. A mental status evaluation was similar to the one in May 2005, except that his affect and mood were abnormal. His mood and motivation were low. There were no obsessional rituals. The diagnosis was PTSD. The Global Assessment of Functioning score was 52. The examiner stated the Veteran had difficulty establishing and maintaining effective work/school and social relationships because of PTSD. The Veteran was most recently afforded a psychiatric examination by the VA in September 2011. He asserted his symptoms included recurring thoughts, nightmares, avoidance of crowds, sleep disturbance, irritability and survivor's guilt. He stated the symptoms were moderate in severity. He described the relationship with his adult children as poor. It was indicated the Veteran had worked in isolation for most of his working career due to difficulty managing social interactions. He claimed he had distressing dreams two to three times a week. A mental status evaluation demonstrated the Veteran's orientation was within normal limits. His hygiene and behavior were appropriate. He had a depressed mood. He appeared dysphoric and tearful during the interview. His concentration was within normal limits. Panic attacks were absent. There was no suspiciousness, and no delusions or hallucinations were observed. There was no obsessive compulsive behavior. The Veteran's thought processes were appropriate. His judgment was not impaired, and his abstract thinking was normal. There was no suicidal or homicidal ideation. No behavioral, cognitive, social, affective or somatic symptoms were attributed to PTSD. The diagnosis was PTSD, and the Global Assessment of Functioning score was 60. The examiner stated the Veteran's psychiatric symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent ability to perform occupational tasks, although he was generally functioning satisfactorily. It was stated his symptoms included depressed mood, anxiety and chronic sleep impairment. The Board notes the only abnormal finding during the November 2005 VA psychiatric examination was that he routinely checked his keys at work. The remainder of the mental status evaluation was essentially normal. Yet, even that examination showed the Veteran had difficulty establishing and maintaining effective work and social relationships. It is apparent he preferred to be alone. The Board acknowledges he expressed suicidal ideation when seen by the VA in December 2006. A disturbance of mood was reported on VA psychiatric examination in September 2007. He reportedly had persistent distressing dreams. He also had marked sleep disturbance, stating he never slept more than two hours at a time. The most recent VA psychiatric examination again demonstrated that the Veteran had worked in isolation for the bulk of his career. He again reported recurrent distressing nightmares, and stated these occurred two to three times weekly. He was dysphoric and tearful. The examiner opined the symptoms of the Veteran's PTSD caused occupational and social impairment. Resolving all reasonable doubt in the Veteran's favor, the Board concludes a 50 percent evaluation is warranted for PTSD. It is evident he was able to work for an extended period of time because he could work alone. While the findings support a 50 percent rating, there is no basis for a higher evaluation. In this regard, while the Veteran reported suicidal ideation on one occasion, the three VA psychiatric examinations show it was not present. There is no indication of any panic attacks, or any impairment in his ability to maintain personal hygiene. His memory is intact. The Board recognizes the Veteran is competent to report symptoms he experiences, such as sleep difficulties and social isolation, and the Board finds him to be credible in this regard. However, the Veteran is not competent to provide an opinion requiring medical knowledge, or a clinical examination by a medical professional, such as an opinion addressing the severity of those symptoms or whether a service-connected disability satisfies specific rating criteria. See Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As a result, his assertions cannot constitute competent medical evidence that his PTSD has increased in severity, so as to warrant a rating in excess of 50 percent. B. Peripheral neuropathy of each lower extremities Neuralgia of the anterior tibial nerve (deep peroneal nerve) is rated under Diagnostic Codes 8723, 8523, 8623 for neuralgia, neuritis, and paralysis of that nerve. A 10 percent rating is warranted when there is moderate incomplete paralysis. Severe incomplete paralysis warrants a 20 percent rating. Complete paralysis, causing the loss of dorsal flexion of the foot, warrants a 30 percent rating. See 38 C.F.R. § 4.124a. A 10 percent evaluation is afforded for mild or moderate incomplete paralysis of the posterior tibial nerve. Severe incomplete paralysis is evaluated as 20 percent disabling. Complete paralysis is evaluated as 30 percent disabling and involves paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature, inability to flex toes, weakened adduction, and impaired plantar flexion. 38 C.F.R. § 4.124a, Diagnostic Code 8725. The May 2005 VA examination shows motor function of the lower extremities was intact. Sensory function was abnormal, with decreased vibration in the right lower extremity. Knee jerks and ankle jerks were 2+ bilaterally. The pertinent diagnosis was peripheral neuropathy. On VA examination in September 2007, a sensory examination was again abnormal. There was decreased sensation to light touch, as well as decreased vibration and pinprick, bilaterally. Knee jerks and ankle jerks were 2+, bilaterally. When examined by the VA in September 2011, motor function of the lower extremities was within normal limits. A sensory examination to pinprick/pain, touch, position, vibration and temperature was intact bilaterally. Knee jerks and ankle jerks were 2+, bilaterally. In order to assign a higher rating for peripheral neuropathy of the right lower extremity, the record must establish the Veteran has moderate incomplete paralysis of the posterior tibial nerve. With respect to the left lower extremity, moderate incomplete paralysis of the anterior tibial nerve must be demonstrated. While some abnormalities were documented on the May 2005 and September 2007 VA examinations, the findings do not support an increased rating. The record does not demonstrate the symptoms are more than moderate in severity. The Board recognizes the Veteran is competent to report symptoms he experiences, such as tingling, and the Board finds him to be credible in this regard. However, the Veteran is not competent to provide an opinion requiring medical knowledge, or a clinical examination by a medical professional, such as an opinion addressing the severity of those symptoms or whether a service-connected disability satisfies specific rating criteria. See Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As a result, his assertions cannot constitute competent medical evidence that peripheral neuropathy of either lower extremity has increased in severity, so as to warrant a rating in excess of 10 percent. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of peripheral neuropathy of the lower extremities. The Board finds, therefore, that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for peripheral neuropathy of either the left lower extremity or the right lower extremity. C. Glaucoma of the left eye The Veteran's service-connected glaucoma has been evaluated under 38 C.F.R. § 4.84a , Diagnostic Codes 6013-6080. The Board notes that the criteria for the evaluation of disabilities of the eyes were amended effective December 10, 2008, but these amended criteria govern cases only when the claim is filed on or after that date. See 73 Fed. Reg. 66543 (November 10, 2008). As the claim in this case was filed prior to December 10, 2008, the revised rating criteria are not applicable. Under Diagnostic Code 6013, glaucoma, simple, primary, noncongestive, is rated based on impairment of visual acuity or field loss. A minimum rating is 10 percent. 38 C.F.R. § 4.84a, Diagnostic Code 6013 (as in effect prior to December 10, 2008). The severity of visual acuity loss is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. Under these criteria, impairment of central visual acuity is evaluated from noncompensable to 100 percent based on the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, Diagnostic Codes 6061 to 6079 (in effect prior to December 10, 2008). A disability rating for visual impairment is based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. § 4.75. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a. Impairment of field of vision is evaluated pursuant to the criteria found in Diagnostic Code 6080. 38 C.F.R. § 4.84a; Diagnostic Code 6080 (in effect prior to December 10, 2008). Under Diagnostic Code 6080, homonymous hemianopsia of the visual field warrants a 30 percent rating, loss of temporal half of the visual field warrants a 30 percent rating if bilateral, a 10 percent rating if unilateral, or is rated as 20/70. Loss of the nasal half of the visual field bilaterally results in a 20 percent rating, unilaterally results in a 10 percent evaluation, or may be rated as 20/50. Id. Concentric contraction of the visual field to 5 degrees, results in a 100 percent evaluation if bilateral, a 30 percent rating if unilateral, or may be rated as 5/200. Concentric contraction of the visual field to 15 degrees but not to 5 degrees results in a 70 percent bilateral evaluation, a 20 percent unilateral rating, or is rated as 20/200. Id. Concentric contraction of the visual field to 30 degrees but not to 15 degrees, bilaterally, results in a 50 percent evaluation, unilaterally results in a 10 percent rating, or is rated as 20/100. Concentric contraction of the visual field to 45 degrees but not to 30 degrees bilaterally results in a 30 percent rating, unilaterally results in a 10 percent evaluation, or is rated as 20/70. Id. A concentric contraction of the visual field to 60 degrees but not to 45 degrees results in a bilateral evaluation of 20 percent, a unilateral evaluation of 10 percent, or rate as 20/50. Demonstrable pathology commensurate with the functional loss will be required. The concentric contraction evaluations require contraction within the stated degrees, temporally; the nasal contraction may be less. 38 C.F.R. § 4.84, Diagnostic Code 6080, Note (2). According to 38 C.F.R. § 4.76, measurement of the visual field will be made when there is disease of the optic nerve or when otherwise indicated. 38 C.F.R. § 4.76a explains how ratings are assigned based on impairment of field vision, as follows. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual field in each of the eight 45 degree principal meridians. The number of degrees lost is determined at each meridian by subtracting the remaining degrees from the normal visual fields given in Table III. The degrees lost are then added together to determine the total degrees lost. This is subtracted from 500. The difference represents the total remaining degrees of visual field. The difference divided by 8 represents the average contraction for rating purposes. 38 C.F.R. § 4.76a. According to Table III in 38 C.F.R. § 4.76a, the normal visual field extent at the 8 principal meridians, in degrees, is: temporally, 85; down temporally, 85; down, 65; down nasally, 50; nasally, 60; up nasally, 55; up, 45; up temporally, 55. The total visual field is 500 degrees. 38 C.F.R. § 4.76a, Table III (2008). The Veteran's service-connected glaucoma may be rated based on visual impairment or visual field testing. The Veteran's visual acuity has been recorded on a number of occasions during his claim. At all times, his corrected visual acuity has been 20/40 or better in each eye. Thus, a higher rating is not warranted based on impairment of vision. The Board also notes that visual field testing was accomplished during the September 2007 VA examination of the eyes. The findings were summarized in the statement of the case issued in August 2008. Thus, the Veteran had actual notice of the results of that test. It was indicated that it was full in the right eye. In the left eye, vision temporally was 60 degrees (85); down temporally was 65 degrees (85); down was 65 degrees (65); down nasally was 50 degrees (50); nasally was 40 degrees (60); up nasally was 50 degrees (55); up was 45 degrees (45); and up temporally was 40 degrees (55). The figures in parentheses refer to the normal visual fields. The examiner stated this demonstrated a generalized constriction in the field in the left eye. The statement of the case noted this revealed the average contraction was 52 degrees. The Board recognizes the Veteran is competent to report symptoms he experiences, such as difficulty with his vision, and the Board finds him to be credible in this regard. However, the Veteran is not competent to provide an opinion requiring medical knowledge, or a clinical examination by a medical professional, such as an opinion addressing the severity of those symptoms or whether a service-connected disability satisfies specific rating criteria. See Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As a result, his assertions cannot constitute competent medical evidence that his glaucoma has increased in severity, so as to warrant a rating in excess of 10 percent. The Board has also considered whether the Veteran's service-connected disabilities present an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case there are no exceptional or unusual factors with regard to the Veteran's disability. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service- connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Total Rating Based on Individual Unemployability Due to Service-Connected Disability (TDIU) Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disabilities at issue render him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. Additional considerations In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, except as otherwise noted, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for herniated nucleus pulposus of the lumbar spine is granted. An evaluation of 50 percent, but not greater, for PTSD is granted, subject to the governing law and regulations pertaining to the payment of monetary benefits. An initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. An initial evaluation in excess of 10 percent for glaucoma of the left eye is denied. REMAND The Veteran also asserts that service connection is warranted for hypertension, to include on a secondary basis. The evidence of record provides conflicting statements regarding the etiology of hypertension. The service treatment records disclose blood pressure was 112/90 in June 1962. All other times during service, the Veteran's blood pressure was within normal limits, to include the December 1966 separation examination. At that time, the heart and vascular system were normal, and blood pressure was 102/56. On the VA examination in February 1998, the list of medical problems included hypertension. When examined by the VA in May 2005, it was reported the Veteran had a history of hypertension for 11 years. Following the examination, the examiner stated the Veteran's hypertension was aggravated by his service-connected diabetes mellitus. The physician added that the degree of the disability due to aggravation could only be determined by speculation. The Veteran was examined in September 2007 by the same examiner who conducted the May 2005 VA examination. At that time, he observed the Veteran had hypertension, and then stated he did not have a non-diabetic condition that was aggravated by diabetes. In light of the conflicting opinions, additional development of the record is necessary. The Board regrets any delay that will result. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran's claims folder to the examiner who conducted the May 2005 and September 2007 examinations and request that he provide an opinion concerning whether it is at least as likely as not (50 percent probability or higher) that the Veteran's hypertension was caused or aggravated (permanently worsened the underlying disorder beyond its normal course) by his service-connected diabetes mellitus. If aggravation occurred, the examiner should quantify, if possible, the extent to which the disability was aggravated. The rationale for any opinion should be set forth. If the examiner who conducted the previous examinations is not available, schedule a VA cardiovascular examination and request the examiner respond to the question set forth above. 2. Following completion of the above, the RO should review the evidence and determine whether the Veteran's claim may be granted. If not, he and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. 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). ______________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs