Citation Nr: 1309040 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 10-46 409 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an increased rating in excess of 10 percent for patellofemoral pain syndrome of the right knee. 2. Entitlement to an increased rating in excess of 10 percent for residuals of right eye injury. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran (Appellant or Claimant) had active duty service from May 1970 to March 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. FINDINGS OF FACT 1. For the entire rating period, the Veteran's service-connected right knee patellofemoral pain syndrome manifested arthritis and pain on motion, but did not manifest flexion limited to 30 degrees, extension limited to 15 degrees, or a combination of extension limited to 10 degrees with flexion limited to 45 degrees, recurrent subluxation or lateral instability, right knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. 2. For the entire rating period, the Veteran's service-connected right eye injury, which includes pseudophakia, traumatic pupil, and epiretinal membrane of the right eye, manifested corrected central visual field acuity of 20/40, average contraction of visual fields of the right eye of 44 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a right knee patellofemoral pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256, 5260, 5261 (2012). 2. The criteria for a rating in excess of 10 percent for residuals of right eye injury have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.3, 4.7, 4.84a, Diagnostic Codes 6029, 6061-6079 (2008); 38 C.F.R. § 4.79, Diagnostic Codes 6029, 6061-6079 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The information required by Vazquez was provided in notice letters dated in July 2009. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's statements. The Veteran was afforded a VA examination for his right knee and right eye disabilities in July 2009. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examinations considered all the pertinent evidence of record, including the Veteran's statements and the claims file. The 2009 knee examination considered all the pertinent evidence of record, including the Veteran's statements and the claims file and provided a clinical examination of the Veteran's knee, which addressed the Veteran's symptoms, range of motion of the knee, and consideration of additional limiting factors including pain, weakness, stiffness, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The VA eye examination addressed the Veteran's eye symptoms and impairment, the Veteran's visual acuity, and confrontation of visual fields. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Ratings - Law and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10 , 4.40, 4.45, and 4.59 must be considered. See DeLuca, 8 Vet. App. 202. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. The Court has stated that the provisions of 38 C.F.R. § 4.59 have bearing even with respect to joint disorders that do not involve arthritis. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court expressly determined that 38 C.F.R. § 4.59 provides for a minimum 10 percent rating for painful, unstable, or malaligned joints that involve residuals of injuries in non-arthritis contexts. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability Rating Criteria for Rating Knee Disability A December 1971 rating decision granted service connection for chondromalacia of the right knee. An initial non-compensable rating was assigned. A 10 percent rating has been in effect since January 1997. A claim for an increased rating was received in June 2009. The Diagnostic Codes (DCs) that are potentially relevant to this case are 5003, 5010, 5256, 5260 and 5261. Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by x-ray findings is rated as degenerative arthritis. 38 C.F.R. § 4.71a , DC 5010. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a . Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; extremely be rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5260 pertains to limitation of flexion. A 10 percent evaluation is assignable when flexion is limited to 45 degrees. A 20 percent evaluation is assignable where flexion is limited to 30 degrees. An evaluation of 30 percent is assignable when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 applies to limitation of extension of the leg. A 10 percent evaluation is assignable for extension limited to 10 degrees. A 20 percent evaluation is assignable for extension limited to 15 degrees. A 30 percent evaluation is assignable for extension limited to 20 degrees. A 40 percent evaluation is assignable for extension limited to 30 degrees. A 50 percent evaluation is assignable when extension is limited to 50 degrees. See 38 C.F.R. § 4.71a. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. VAOPGCPREC 23-97. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98. The VA General Counsel has also directed that separate ratings are available if a particular knee condition causes both the limitation of extension and limitation of flexion of the same joint. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04. Increased Rating for Patellofemoral Pain Syndrome of the Right Knee The Veteran seeks an increased rating in excess of 10 percent for patellofemoral pain syndrome of the right knee. The Veteran contends that he has pain and stiffness in the right knee. The Veteran contends that there are pieces of equipment at work that he cannot operate because his knee prevents him from climbing ladders. After a review of all of the evidence, the Board finds that, for the entire rating period, the Veteran's service-connected patellofemoral pain syndrome manifested arthritis and pain on motion, but did not manifest flexion limited to 30 degrees, extension limited to 15 degrees, or a combination of extension limited to 10 degrees with flexion limited to 45 degrees, recurrent subluxation or lateral instability, right knee ankylosis, impairment of the tibia and fibula, or genu recurvatum, which is consistent with a rating of not more than 10 percent under any Diagnostic Code. 38 C.F.R. § 4.71a. A letter from Dr. L.M., dated in July 2009, reflects that the Veteran was evaluated for difficulties with his knees. Dr. L.M. indicated that examination of the right knee showed pain and crepitus associated with the patella femoral joint consistent with significant chondromalacia patella. The report noted that radiographs of the knee were taken and demonstrated chondromalacia patella of the right knee, causing pain, swelling, and crepitus. The Veteran had a VA examination in August 2009. The Veteran reported that, in the last few years, he had knee pain daily that was worse with walking, going up and down stairs, or running. The Veteran denied buckling, locking, and instability. He denied problems with repetitive use and flare-ups. The VA examiner noted that there was no interference with his job or daily activities reported. Physical examination of the right knee in August 2009 revealed no swelling, no cellulitis, and no deformities. The VA examiner noted a positive patellar grind test. There was medial joint line tenderness. McMurray's sign was negative. The Veteran had extension of the knee to 0 degrees and flexion to 140 degrees. He complained of pain throughout. There was no instability to varus, valgus, anterior, or posterior stressing. The VA examiner indicated that, after repetitive motion of the right knee, there was no additional limitation of joint function due to pain, fatigue, or lack of endurance. The VA examiner's assessment was right knee patellofemoral syndrome. The Board finds that, based on all of the evidence, the Veteran's patellofemoral pain syndrome of the right knee does not more nearly approximate the criteria for a rating in excess of 10 percent for any period. During the entire rating period, the Veteran's right knee disability manifested arthritis and pain on motion, but did not manifest flexion limited to 30 degrees, extension limited to 15 degrees, recurrent subluxation or lateral instability, right knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. As the evidence shows that the Veteran's right knee patellofemoral pain syndrome has been manifested by flexion of 140 degrees and full extension of 0 degrees during the appeal period, a higher rating is not assignable under the criteria for Diagnostic Codds 5260 or 5261 based upon limitation of extension or limitation of flexion. Likewise, as the evidence does not show a combination of extension limited to 10 degrees with flexion limited to 45 degrees, separate compensable ratings for limitation of extension (Diagnostic Code 5261) and limitation of flexion (Diagnostic Code 5260) are not warranted. See VAOPGCPREC 9-04. In addition, as 10 percent is the maximum rating provided under Diagnostic Codes 5010-5003, a higher rating is not possible under this code. The Board has considered whether a higher rating is warranted based upon additional limitation of motion due to orthopedic factors, such as pain, guarding of movement, and fatigability. See DeLuca, supra.; 38 C.F.R. §§ 4.45, 4.59. The August 2009 VA examination showed that there was no objective evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. Even with consideration of additional limitation of motion and function due to pain, weakness, and stiffness, the weight of the evidence shows that the Veteran's right knee patellofemoral pain syndrome does not more nearly approximate the criteria for a rating in excess of 10 percent for limitation of flexion or limitation of extension. The 2009 VA examiner indicated that the Veteran experiences pain throughout ranges of motion. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. The evidence does not show that pain limits flexion of the right knee to 30 degrees, as required for a higher disability rating of 20 percent under Diagnostic Code 5260, or that pain limits extension to 15 degrees, as required for a 20 percent rating under Diagnostic Code 5261. Diagnostic Code 5257 governs recurrent subluxation or lateral instability. A 10 percent evaluation is assignable for slight recurrent subluxation or lateral instability. A 20 percent evaluation is assignable for moderate recurrent subluxation or instability. A 30 percent evaluation is provided for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. In this case, there are no complaints or objective findings of instability of the right knee. The Veteran denied instability of the knee upon examination in 2009, and the VA examiner indicated that instability was not present. Accordingly, the Board finds that a separate compensable rating is not warranted for instability of the right knee under Diagnostic Code 5257. A higher rating than 10 percent is not assignable under Diagnostic Code 5256, as ankylosis of the knee is not shown by the evidence of record. "Ankylosis" is defined as immobility of a joint. Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). "Ankylosis" is immobility and consolidation of a joint due to disease, injury, surgical procedure. Nix v. Brown, 4 Vet. App. 462, 465 (1993); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). "Ankylosis" is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). While the 2009 VA examiner indicated that the Veteran experiences pain throughout ranges of motion, such general reports of pain throughout the entire ranges of motion from 0 to 140 degrees, without indication of a point of onset of pain or any point of worsening of pain, and in the context of the examiner's specific notations of ranges of motion and the clinical findings that do not suggest severity of disability of the right knee to cause knee pain throughout all ranges of motion, the Board finds that the Veteran's reports of pain do not affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, so as to constitute functional loss. The Veteran's generalized reports of pain do not constitute functional loss, including complete functional loss to demonstrate ankylosis. Mitchell, 25 Vet. App. 32. A higher rating is also not warranted under either Diagnostic Codes 5262 or 5263, as the evidence does not show impairment of the tibia or genu recurvatum. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 10 percent for any period for patellofemoral pain syndrome of the right knee, including the assignment of a separate rating for subluxation or lateral instability under Diagnostic Code 5257. As there is a preponderance of the evidence against the claim for an increased rating for patellofemoral pain syndrome of the right knee, the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Residuals of Right Eye Injury Service connection for residual of right eye injury was granted in a January 1973 rating decision. A 10 percent rating has been in effect for residual of right eye injury since March 1972. The Veteran's claim for an increased rating was received in June 2009. The Veteran contends that a higher rating is warranted for residual of right eye injury. He alleges that he has photophobia in his right eye as a result of the surgery that was performed during service. He also alleges that the right eye injury in service has required surgeries on his right eye after service that also resulted in eye disability. During the course of this appeal, VA revised the criteria for rating eye disabilities, effective December 10, 2008. 73 Fed. Reg. 66,543 (2008). The December 2008 amendments included a rearrangement of some substantive criteria for rating eye disabilities, which ultimately eliminated 38 C.F.R. § 4.84a (2008). The current version of the schedule for rating the eye is located in 38 C.F.R. § 4.79 (2012). In VAOPGCPREC 3-2000, VA's General Counsel interpreted that, when a provision of the VA rating schedule is amended while a claim for an increased rating under that provision is pending, a determination as to whether the intervening change is more favorable to the veteran should be made. If the amendment is more favorable, that provision should be applied to rate the disability for periods from and after the effective date of the regulatory change; and the prior regulation should be applied to rate the veteran's disability for periods preceding the effective date of the regulatory change. The effective date of a liberalizing law or VA issue is no earlier than the effective date of the change. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012). The criteria in effect prior to December 10, 2008 provided that unhealed injury of the eye was rated according to Diagnostic Code 6009. The disabilities listed at Diagnostic Codes 6000 to 6009, in chronic form, were to be rated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum 10 percent rating was assignable during active pathology. 38 C.F.R. § 4.84a (2008). The criteria in effect from December 10, 2008 provide that the disabilities listed at Diagnostic Codes 6000 through 6009 are to be evaluated on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. 38 C.F.R. § 4.79. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks over the past 12 months. 38 C.F.R. § 4.79 (2012). The Board notes that service connection is not in effect for a left eye disability. Subject to the provisions of 38 C.F.R. § 3.383(a), if visual impairment of only one eye is service connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75(c) (2012). The criteria pertaining to impairment of visual fields in effect both before and after December 10, 2008 provide that the extent of visual field contraction in each eye was determined by recording the extent of the remaining visual fields 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 38 C.F.R. § 4.76a, Table III (2012). The degrees lost were then added together to determine total degrees lost. This was subtracted from 500. The difference represents the total remaining degrees of visual field. The difference divided by eight represents the average contraction for rating purposes. Table III provides that the normal visual field extent at 8 principal medians is as follows : 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up and 55 degrees up temporally. 38 C.F.R. § 4.76a (2012). A December 2007 statement from a private physician, Dr. Coniaris, noted that the Veteran had a traumatic cataract of the right eye, which was now resolved, status post surgery. At a VA eye disorders examination in July 2009, the Veteran reported a history of shrapnel in the right eye in 1971, that his vision was blurred due to the injury in the right eye, and the pupil did not adjust to light from the shrapnel injury in the right eye. The Veteran reported headaches when indoors and from bright light, and that he had a "caruncle" removed from his right eye three months prior to the VA examination. Upon examination in July 2009, the best corrected distance visual acuity was 20/40 in the right eye. The best corrected near visual acuity in the right eye was 20/30. Extraocular movements were full in both eyes. Confrontation visual fields revealed a defect supertemporal and inferonasal in the right eye. The pupils were unequal in size. The iris of the right eye showed a surgical pupil, and the left iris was clear. In the right eye, there was a posterior chamber intraocular lens implant. There was a surgical pupil noted in the right eye and no afferent pupillary defect. The VA examiner diagnosed traumatic pupil, right eye, pseudoaphakia, right eye, and epiretinal membrane, right eye. Visual field examination in July 2009 showed that the Veteran's field of vision temporally was 55 degrees as compared to 85 degrees normal. Temporally down field of vision was 58 degrees as compared to 85 degrees normal. Down field of vision was 42 degrees as compared to 65 degrees normal. Down nasally field of vision was 35 degrees as compared to 50 degrees normal. Nasally field of vision was 40 degrees, as compared to 60 degrees normal. Up nasally field of vision was 40 degrees, as compared to 55 degrees normal. Up field of vision was 35 degrees, as compared to 45 degrees normal. Up temporally, field of vision was 45 degrees, as compared to 55 degrees normal. Total remaining field of vision was 350. The average contracted visual field was 350 divided by eight and rounded up, which was 44 degrees. Based upon the July 2009 VA examination, the Veteran's concentric contraction in the right eye is 44 degrees. Under the versions of Diagnostic Code 6080 both before and after December 10, 2008, a 10 percent rating is assignable. The rating criteria also provide that this impairment of field vision may be rated as 20/70. This would result in a 10 percent evaluation under either the prior or the revised rating criteria. The July 2009 VA examination report reflects that the VA examiner diagnosed traumatic pupil, pseudophakia of the right eye, and epiretinal membrane right eye. The Veteran now has pseudophakia, but does not have aphakia (an absence of the lens of the eye), which would warrant a rating under different criteria. Pseudophakia has two meanings - one is a condition where the lens has been replaced status post-cataract removal, and the other is a condition in which a degenerated lens is spontaneously replaced by some other type of tissue. 64 Federal Register, 25246, 25252, May 10, 1999. Aphakia is defined as an absence of the lens of the eye. Hazzard v. Brown, 4 Vet. App. 254, 256 (1993) and Flash v. Brown, 8 Vet. App. 332 (1995). "[T]here is substantial magnification of the image in an aphakic eye, peripheral vision is reduced, and with aphakia of a single eye, image fusion may be difficult because of the great difference in refraction between the eyes. Glare and photophobia are common additional problems, and eyeglasses cause a ring scotoma so that objects appear to jump in and out of view." 64 Federal Register, 25246, 25252, May 10, 1999. The VA examiner in July 2009 did not specifically address whether the findings of traumatic pupil, pseudophakia, and epiretinal membrane are residual to the service-connected right eye injury; however given the history of in-service trauma to the eye, with multiple retained foreign bodies and peripheral iridectomy in service, the Board concludes that the VA the examiner's diagnosis reasonably associates the Veteran's current right eye diagnoses, or at least does not differentiate such complications or further disorders of the eye from the service-connected shrapnel wound injury. The diagnosis of "traumatic" pupil is suggestive of a trauma as the etiology of this disorder, as the only trauma to the right eye that is indicated in the record is the in-service shrapnel injury. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so). Diagnostic Code 6027 pertains to cataract of any type. For a postoperative cataract, if a replacement lens is present (pseudoaphakia), the condition is to be evaluated based on visual impairment. If there is no replacement lens, cataracts are to be evaluated based on aphakia. In this case, a replacement lens is present. Therefore, according to Diagnostic Code 6027, his right eye disability is evaluated based upon visual impairment. The Veteran's visual impairment is 20/ 40 in the right eye. The visual impairment in the nonservice-connected left eye is assumed to be 20/40 for rating purposes. The criteria pertaining to impairment of visual acuity provide that a non-compensable rating is warranted for this degree of visual impairment. Diagnostic Code 6079 (2008); Diagnostic Code 6066 (2012). The Board has also considered whether a higher rating is assignable for epiretinal membrane of the right eye. Under Diagnostic Code 6011, a 10 percent rating is assignable for retinal scars, atrophy, or irregularities, unilateral or bilateral, that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image. 38 C.F.R. § 4.79 (2012). The 10 percent rating is the maximum rating available under Diagnostic Code 6011; therefore, evaluating the Veteran's residuals of right eye injury under Diagnostic Code 6011 does not provide a higher rating that the 10 percent rating already assigned. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 10 percent for any period for residuals of right eye injury. As there is a preponderance of the evidence against the claim for an increased rating for residuals of right eye injury, the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the schedular rating criteria contemplate the Veteran's disabilities. The rating criteria pertaining to the Veteran's service-connected right knee disability consider the range of motion of the knee, whether there is subluxation or instability and whether ankylosis is present. The rating criteria for the knee also consider limitation of motion of the knee, including due to pain and other orthopedic factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. The rating criteria for the Veteran's right eye injury provide for ratings based on incapacitating episodes(Diagnostic Code 6009), impairment of visual acuity (Diagnostic Code 6066), or impairment of visual fields (Diagnostic Code 6080), and a potential alternative rating for damage to the epiretinal membrane as a retinal scar or irregularity (Diagnostic Code 6011). 38 C.F.R. § 4.79. Because the schedular rating criteria are adequate to rate the Veteran's disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER A rating in excess of 10 percent for patellofemoral pain syndrome of the right knee is denied. A rating in excess of 10 percent for residuals of right eye injury is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs