Citation Nr: 1310318 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 06-28 178 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an eye disorder. 3. Entitlement to a compensable rating for vascular headaches. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran served on active duty from May 1979 to February 1988. This case comes before the Board of Veterans' Appeals (Board) from a rating decision of December 2005 from the Philadelphia, Pennsylvania Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the claims on appeal. While the appeal was pending, the case was transferred to the RO in Boston, Massachusetts. The Veteran's claims were previously before the Board and remanded in October 2009 for additional development. With regard to the claim of entitlement to a compensable rating for vascular headaches, the Board finds that the Veteran was afforded a VA examination to ascertain the current symptomatology associated with this disability, as was directed by the Board's remand. As such, with regard to this issue, additional remand is not required. Stegall v. West, 11 Vet. App. 268 (1998). While the Veteran was previously represented by Disabled American Veterans, in January 2012, he completed a VA Form 21-22, appointing the Military Order of the Purple Heart. The Board recognizes this change in representation. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. A review of the documents in the electronic file reveals that there are medical records pertinent to the claim decided herein. In a November 2012 written statement, the Veteran's accredited representative waived RO review of this evidence, and, therefore, the Board may proceed with this claim. As noted in the Board's October 2009 remand, the issue of entitlement to service connection for residuals of a cerebrovascular accident (CVA), claimed as secondary to the service-connected headaches, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and entitlement to service connection for an eye disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to December 12, 2008, the Veteran's vascular headaches are characterized by prostrating attacks averaging one per month and a slight impact on occupational functioning. 2. From December 12, 2008, the Veteran's vascular headaches are characterized by very frequent, completely prostrating and prolonged attacks, productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating for vascular headaches, prior to December 12, 2008, are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2012). 2. The criteria for a 50 percent rating for vascular headaches, from December 12, 2008, are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, notice dated in March 2005 informed the Veteran of what evidence VA would seek to provide and what evidence the Veteran was responsible for providing. He was informed that, in order to substantiate his claim, the evidence needed to show that his disability had worsened. Thereafter, the Veteran's claim was initially adjudicated in June 2004. A February 2008 letter issued to the Veteran contained notice regarding the assignment of disability ratings and effective dates, pursuant to the requirements of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), and an October 2008 letter contained the rating criteria used to evaluate the Veteran's service-connected headaches. Thereafter, an August 2011 supplemental statement of the case reflects readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Next, VA has a duty to assist the Veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). In this case, the RO has secured all of the pertinent medical records identified by the Veteran, which consists of VA treatment records. Furthermore, he was afforded VA examinations pertinent to his claim in September 2005, December 2008, and November 2010, for which an addendum was obtained in August 2011. The examinations were conducted by medical professionals, who solicited symptomatology from the Veteran and conducted complete evaluations. Taken together, the Board finds that they are adequate to serve as a basis for this decision. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's headaches are currently rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, migraines are rated as follows: a 0 percent rating is assigned with less frequent attacks; a 10 percent rating is assigned with characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months; and a 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The rating criteria do not define "prostrating." Dorland's Illustrated Medical Dictionary defines "prostration" as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). An April 2005 VA outpatient treatment record shows that the Veteran had a history of severe migraines. In September 2005, the Veteran underwent VA examination. However, no symptomatology was obtained or examination was conducted with reference to the Veteran's headaches. Nevertheless, a diagnosis of chronic intermittent headaches was given. A January 2006 VA outpatient report indicates that the Veteran had complicated migraines, which were likely retinal migraines causing blurry vision. He was not currently being treated, but there was evidence of medication overuse. He had a three to four year history of continuous daily ibuprofen use. He was prescribed Topamax for his migraines. An April 2006 VA treatment record shows that the Veteran had been previously seen in the emergency room with complaints of a headache. It was right-sided, throbbing, and associated with blurry vision in his right eye. He noted that this occurred two to three times per month for the past three years. He was seen by neurology in the emergency room and diagnosed with a complicated migraine. Headache was the diagnosis. A May 2006 VA neurology record shows that the Veteran described his typical migraine as bi-frontal and bi-occipital with throbbing pain that did not involve the vertex or temporoparietal regions. They occurred about every two months and lasted two to four hours. However, his current headache had been present for five days. He described light and sound sensitivity. Usually, the headaches resolved in a few hours. He did not need to move to a quiet room or lie down. If he was at work, he just continued working. Following evaluation, the physician noted the Veteran's complaints and said they were not classically migrainous. However, she noted a prior medical history that likely included complicated migraines, given the Veteran's prior diagnoses and the similarity of those complaints to the ones he now endorsed. A June 2006 VA outpatient record shows that the Veteran continued to have frequent migraines and had been seen by neurology, which diagnosed complicated migraines. He had been given prescription medication. An October 2006 VA treatment report shows that the Veteran reported experiencing a migraine headache every other day for the past week. They started at the bilateral temples and went across the front of his head. He also experienced them occipitally. He used to get them once a month but now experienced them once or twice a week. The physician noted that the headaches did not sound like migraine headaches and that the Veteran gave a varying history of his symptoms. On December 12, 2008, the Veteran underwent VA examination. He reported a history of posterior headaches, which began after the first of two accidents during service. He developed headaches shortly after these head injuries, which were similar but less severe in quality than the ones he experienced now. They were bilateral and suboccipital and sharp at times. They were associated with photosensitivity and nausea but not visual aura. Initially, they occurred several times per month and lasted twenty minutes. He got the most benefit from lying down in a quiet room and trying to sleep. Over the last four months, he experienced a significant increase in headaches, in terms of duration and intensity. They lasted 45 minutes to an hour and responded to trying to sleep in a dark room. They occurred four to five times per week and impaired his ability to work. He stopped working one year ago for numerous reasons, that included his headaches and mood problems. The examiner noted VA treatment for arthritis of the cervical spine and some discussion as to whether the cervical spine disease contributed to the Veteran's headaches. The Veteran indicated that certain postures induced headaches, but he denied any neck pain that preceded the posterior suboccipital headaches. Watching television and looking at a computer screen also brought on headaches. General stress was also a factor. Prior medications have helped at times. Following examination, the impression was posterior headaches with qualities of tension headaches and some mixed migrainous symptoms. The examiner indicated that there may be a musculoskeletal trigger, possibly occipital neuralgia. A high cervical radiculopathy also remained a question of a trigger, however, degenerative disease was most prominent below C3, which would be less typical for this. The headache condition, by history, was more likely than not connected to active service. In November 2010, the Veteran underwent VA examination. His claims file was reviewed. He report that, since his fall during service, he had on and off pain in the back of his neck and occipital region that made its way to the frontal region. The headaches were associated with sensitivity to light but no nausea or vomiting. The Veteran stopped working in 2007 due to a problem at work and difficulty dealing with all of his injuries from service. Examination in 2009 revealed degenerative joint and disc disease of the cervical spine. During a neurological consult a few years ago, the Veteran reported that he was told that his headaches came from the problem in his neck. Following examination, the examiner indicated that the Veteran presented with occipital neuralgia related to degenerative joint disease in the cervical region. The only risk factors were a fall during service. The signs and symptoms discussed therein were service-connected. In August 2011, the RO contacted the examiner that conducted the November 2010 VA examination. The examiner indicated that she was not typically presented with what conditions the Veteran was service connected for, so she did not know that the Veteran was service-connected for vascular headaches. When she saw him, the Veteran indicated that the pain began at the back of his head and made its way to the front, which was indicative of occipital neuralgia. She commented that most headaches were commonly known as vascular headaches or tension headaches. In this case, she thought it was appropriate to diagnose the Veteran with occipital neuralgia. Furthermore, the occipital neuralgia was due to the cervical degenerative joint disease. Based on the evidence of record, the Board finds that an increase to a 30 percent rating under the criteria of Diagnostic Code 8100 is warranted prior to December 12, 2008. Since February 2004 when the Veteran submitted his claim for increase, he has given numerous reports as to the symptomatology associated with his headaches. He has always reported such headaches, which varied in frequency from once every two months to several times per week. At times, they were not prostrating, but at other times, he needed to lie down in a dark room in order for the headache to subside. The Board finds that, as a whole, prior to December 12, 2008, the Veteran has demonstrated the criteria needed for a 30 percent disability rating under Diagnostic Code 8100, which is warranted when there are prostrating attacks that occur on average once a month. Occasionally, the Veteran experienced headaches more often that this, but they were not prostrating. While he sometimes experienced such attacks less often than once per month, the Board finds that the disability picture, as a whole, reflects an average of one characteristic prostrating attack per month. Furthermore, the Board finds that a 50 percent rating is warranted from December 12, 2008, the date on which the Veteran underwent a VA examination. This is also the first date on which the Veteran reported that his headaches impacted his occupation in any significant way. While he previously reported in 2006 that he had experienced multiple headaches in one week, he also stated that they did not affect his ability to work, as he just continued to work through them. Therefore, severe economic inadaptability is not shown until the Veteran alleges that his headaches interfere with his job during the December 12, 2008 VA examination. While the Veteran indicated that he stopped working in 2007, it was due to numerous reasons, only one of which was his headaches. Significant impact on employment caused by the headaches alone is not shown until the Veteran was examined in December 2008 VA. The 30 percent disability rating now assigned prior to December 12, 2008 reflects a level of impairment of occupational functioning due to the Veteran's headaches. Severe economic inadaptability due to headaches is not shown or suggested by the medical or lay evidence prior to that date. The Board notes that there is some conflicting evidence of record as to the source of the Veteran's headaches. The most recent VA examination dated in November 2010, with the addendum dated in August 2011, indicates that the examiner believed the Veteran had occipital neuralgia, which was due to his cervical degenerative joint disease, a nonservice-connected disability. This was based upon the Veteran's cervical diagnosis and his description of headache symptomatology. However, the Board finds that the other medical evidence of record contains diagnoses of headaches, to include migraines. Furthermore, the headaches described by the Veteran when he was first examined for VA purposes in July 1989 are nearly identical in symptomatology to the headaches he described in November 2010, for which the examiner diagnosed occipital neuralgia. In addition, while the examiner found that the occipital neuralgia was due to cervical spine arthritis, the Board notes that the Veteran's headaches were present in service and on examination in 1989, several years before he ever complained of or was diagnosed as having a cervical spine disability. Therefore, resolving all doubt in the Veteran's favor, the Board finds that the balance of the evidence shows that, to at least some extent, the Veteran's current complaints of headaches are due to his service-connected disability. To the extent that his complaints are caused by occipital neuralgia due to a cervical spine disability, there is no medical or lay evidence that allows the Board to separate the symptomatology due to the service-connected disability from that of the nonservice-connected disability. As such, all symptomatology will be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Therefore, the Board concludes that the evidence supports a finding that a 30 percent disability rating is warranted under Diagnostic Code 8100 prior to December 12, 2008, and a 50 percent rating is warranted thereafter. There are no other potentially applicable rating criteria. To the extent that the Veteran seeks even higher disability ratings than those assigned herein, the evidence preponderates against such a finding. As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's vascular headaches are fully contemplated by the applicable rating criteria. All of the symptomatology described by the Veteran is contemplated in the rating criteria used to assign the 30 and 50 percent ratings. The Veteran has not endorsed any symptoms that are not contemplated by the rating schedule. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. While the Veteran indicated that his headaches caused some impact on his employment and there is one record showing emergency room treatment for a headache, this is contemplated in the disability rating now assigned. The Veteran was no longer working for numerous reasons, only one of which was his headache disability. Therefore, referral for consideration of an extraschedular rating for the Veteran's vascular headache disability is not warranted. 38 C.F.R. § 3.321(b)(1). For the foregoing reasons, the preponderance of the evidence warrants a 30 percent rating for vascular headaches prior to December 12, 2008 and a 50 percent rating thereafter. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be granted to the extent indicated. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER A 30 percent rating for vascular headaches is granted prior to December 12, 2008, subject to the laws and regulations governing the payment of VA benefits. A 50 percent rating for vascular headaches is granted from December 12, 2008, subject to the laws and regulations governing the payment of VA benefits. REMAND The Board finds that additional development is warranted prior to final adjudication of the claims of entitlement to service connection for a psychiatric disorder and an eye disorder. Psychiatric Disorder In the Board's October 2009 remand, we directed that the AOJ should make attempts to confirm the Veteran's claimed stressors, which were listed in the Board's remand. This included obtaining the Veteran's service personnel records, submitting the information to the Joint Service Records Research Center (JSRRC), and scheduling the Veteran for a VA examination, if one is deemed warranted. The Veteran has put forth two stressors that contain enough detail for attempts to be made at corroboration. They are discussed in more detail in the October 2009 remand. One involves the Veteran having to guard a gate while stationed in Germany, during which he exchanged fire with terrorists. One involves having been in a motor vehicle accident while stationed in German. The last alleged stressor involves having been in combat in Nicaragua in 1986 or 1987 during a counter insurgency operation. The Veteran's service personnel file was obtained and associated with the claims file. In a September 2010 VA memorandum, a person who is a member of the JSRRC team indicated that the Veteran's personnel file verified that he was assigned to B Company, 3/34th Armor Regiments, Nurnberg, Germany from February 1984 to November 1985. While the specific incident he described regarding his service in Germany was not independently verified, it related to his fear of hostile military or terrorist activity and was consistent with the places, types, and circumstances of his service. In April 2011, the AOJ contacted the U.S. Army Crime Records Center and asked for any evidence that the Veteran was involved in a firefight with a terrorist while stationed in Nurnberg, Germany. The reply, which was received in June 2011, was that there were no such records. In July 2011, the AOJ sent a request to the JSRRC to attempt to verify the Veteran's stressors of having been involved in a terrorist firefight in Germany and having been engaged in combat in Nicaragua. No response from the JSRRC is contained in the claims file. In August 2011, the Veteran was afforded a VA examination. In that report, the examiner notes that the Veteran had a previous examination in February 2011. The report of this examination is not of record in either the physical or virtual files. He described his claimed stressor of having engaged in combat in Nicaragua and an incident in Germany when there was an airplane crash that killed friends that he had taken to the airport. A diagnosis of PTSD was given based upon the reported stressors. In an August 2011 memorandum, a ratings operation manager at the AMC wrote that the Veteran was not involved in special operations or antiterrorism during service, based upon information contained in his personnel file, which lacked the requisite military occupational specialty and security clearances. Therefore, to the extent that the Veteran contended that he was involved in such assignments, his statements were not credible. Since this claim was last remanded by the Board in October 2009, a revision was made to the criteria used to determine whether a stressor required independent verification in the context of a claim of entitlement to service connection for PTSD. Specifically, the revision indicated that, if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). With regard to the claimed stressor that the Veteran was involved in combat while stationed in Nicaragua, his service personnel records contain no evidence that he was ever stationed in Nicaragua. Therefore, this stressor, based on the evidence of record, is not consistent with the circumstances of his service. However, the Veteran was called to participate in Kindle Liberty 87 in January 1987 and sent to Panama. In April 2011, the AOJ requested information from the JSRRC regarding this claimed stressor. However, the JSRRC did not respond, and the AOJ never initiated more contact or sent a second request. The Board finds that this should be accomplished on remand. The AOJ's JSRRC team determined that the Veteran's claimed stressor of having been involved in a firefight with a terrorist while stationed and working as a guard in Germany was consistent with the circumstances of his service. However, when the Veteran was examined in August 2011, the examiner did not discuss this stressor. Therefore, the Veteran should be afforded another examination, and the examiner should be informed which stressors have been verified or determined to have been consistent with the circumstances of the Veteran's service prior to rendering an opinion or diagnosis. Eye Disorder In the October 2009 remand, the Board directed that the Veteran be scheduled for a VA examination with a specialist to determine the nature and etiology of his claimed eye disorder. The examiner was asked to comment on whether any currently diagnosed eye disorder was related to service. If any disorder was not directly related to service, the examiner was asked to provide an opinion as to whether it was caused or aggravated beyond its normal progression by the Veteran's service-connected headaches or by his residuals of a cerebrovascular accident. The examiner was asked to provide a rationale for any opinion given. In January 2011, the Veteran was afforded a VA examination. The assessment was a history of idiopathic central serous chorioretinopathy of the right eye, which had resolved. There was normal retinal structure of each eye on examination at this time. However, the examiner noted that there was pigment disruption noted as far back as 2004, and bilateral vision dropped in 2006, which was likely a pigment epithelial detachment from idiopathic central serous choroidopathy. A small pigment epithelial detachment was confirmed in 2008. It resolved in February 2009 and remained resolved. Other impressions included non-visually significant cataracts and refractive error, presbyopia. The examiner commented that the Veteran had no ocular adverse reactions secondary to night fire, since visual acuity, visual field, and retinal structure was normal in both eyes. The Veteran filed the claim that led to the appeal in this case in February 2004. Therefore, according to the VA examiner's report, the Veteran had a diagnosed retinal disorder during the appeal period. The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement for service connection has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As such, the rationale provided by the VA examiner is inadequate because it relies on the absence of a current diagnosis. While it appears that the Veteran no longer has a retinal disability, he manifested one during the course of the appeal, and an opinion as to whether this disability was related to service or aggravated by a service-connected disability is needed prior to final adjudication of this claim. Accordingly, the case is REMANDED for the following action: 1. Contact the JSRRC and send a second request for corroboration for the Veteran's claim stressor of having been in combat in Nicaragua in 1986 or 1987 during a counter insurgency operation. The JSRRC should be requested to provide any information which might corroborate the Veteran's alleged stressor. Requests should be made until either the information is located or it is determined that additional requests would be futile. 2. Thereafter, the AOJ should afford the Veteran a VA psychiatric examination. The claims file, along with a copy of any pertinent records from the virtual file, must be provided to the examiner for review prior and pursuant to conduction and completion of the examination. The examiner should also be told which stressors have been corroborated or determined to have been consistent with the circumstances of the Veteran's service prior to rendering an opinion. The examiner must determine the nature, severity, and etiology of any psychiatric disorder(s) present, to include PTSD. The examiner should provide an opinion on the following: a. Does the Veteran have a diagnosis of PTSD? b. If PTSD is diagnosed, the examiner MUST identify the stressor(s) supporting the diagnosis of PTSD. In identifying any claimed stressor(s) the examiner should independently review the entire record. After consideration of these stressors, the examiner should explain whether they satisfy the criteria to support a diagnosis of PTSD; c. If PTSD is not diagnosed or if there are additional psychiatric disorders, the examiner should opine as to whether any such disorder(s) is/are related to service, or if preexisting service, was/were aggravated thereby. The examiner should utilize the DSM-IV in arriving at diagnoses and identify all existing psychiatric diagnoses. The report of the examination should include a complete rationale for all opinions. 3. Following completion of the above, the AOJ should schedule the Veteran for an eye disorders examination, by an appropriate specialist, to determine the nature and etiology of the Veteran's claimed eye disorder. The claims folder must be made available to the examiner prior to the examination, and the examiner should acknowledge such review of the pertinent evidence in the examination report. All indicated studies should be performed and all manifestations of current disability should be described in detail. The examiner should address the following: Has the Veteran manifested any eye disorder since February 2004? If so, is it at least as likely as not that any such disorder began in service? The findings in the service treatment records showing treatment for the eyes should be addressed in answering this question. If any eye disorder did not begin in service, is it at least as likely as not that any such disorder or disorders is/are being caused or aggravated beyond natural progression by symptoms caused by the service-connected headache disorder, or by residuals of a cerebrovascular accident? Each opinion should contain a comprehensive rationale based on sound medical principles and facts. 4. After undertaking any other development deemed essential in addition to that specified above, the AOJ should re-adjudicate the Veteran's claims. If any benefit sought on appeal remains denied, the Veteran should be provided a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and discussion of all pertinent regulations. An appropriate period of time should be allowed for response. 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). ______________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs