Citation Nr: 1311070 Decision Date: 04/03/13 Archive Date: 04/19/13 DOCKET NO. 00-05 786 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a heart disability, to include as due to herbicide exposure and/or service-connected generalized anxiety disorder. 2. Entitlement to service connection for a gastrointestinal disability, to include as due to herbicide exposure. 3. Entitlement to service connection for a sinus disability, to include as due to herbicide exposure. 4. Entitlement to service connection for a headache disorder, to include as due to herbicide exposure and/or a sinus disability. 5. Entitlement to service connection for a vision disorder, to include as due to herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1965 to February 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal from adverse action by the Department of Veterans Affairs (hereinafter VA) Regional Office in Montgomery, Alabama, (hereinafter RO). The case was previously before the Board and remanded many times, most recently in July 2012. In the July 2012 remand, the Board noted that additional service department records were received into evidence in October 2011. Therefore, the Board found that new and material evidence was not needed to reopen the service connection claims on appeal, and that the prior and final October 1996 decision RO decision should be reconsidered on a de novo basis. See 38 C.F.R. § 3.156 (c) (2012). The Board then remanded the service connection claims on the merits for further development. The issue of entitlement to a total disability rating based upon individuals unemployability 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 service connection for gastrointestinal and headache disabilities 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. Service records do not show that the Veteran served in Vietnam, and the evidence does not establish that he was exposed to Agent Orange in service. 2. While the Veteran served during the Vietnam Era, he did not have service in the Republic of Vietnam and is therefore not entitled to presumptive service connection for a heart condition based on presumed in-service herbicide exposure. 3. The Veteran does not have currently-diagnosed heart disease. 4. The most probative medical evidence of record does not establish that the Veteran currently suffers from a chronic sinus condition or that a claimed sinus condition is related to service or a service-connected disability. 5. The Veteran was first diagnosed with amblyopia and noted to have depth perception problems in service, and he has credibly reported continued problems with depth perception. CONCLUSIONS OF LAW 1. The criteria for service connection for heart disease have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a sinus disorder have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.310 (2012). 3. The criteria for service connection for a chronic vision disorder diagnosed as amblyopia have been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The VA has a duty to provide notification to the Veteran with to respect establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). VA's notice requirements were satisfied by a letters issued in February 2003 and December 2007, which apprised the Veteran of the criteria for establishing service connection; the evidence he was responsible for obtaining and the evidence VA would obtain on his behalf; and the methods by which VA determines disability ratings and effective dates. The Board notes that August 2011 and October 2011 letters provided the Veteran with the necessary information concerning his claims based on herbicide exposure. The Board is cognizant that the Veteran was not provided notice of how to establish service connection for heart disease on a secondary basis until the most recent adjudication of his claim in a supplemental statement of the case issued in January 2013. Nevertheless, the Board finds that the Veteran is not prejudiced by a lack of prior notice, as he had been previously notified of and failed to meet the threshold requirement to establish service connection on any basis, that of a current disability. Moreover, the Board finds that the Veteran's specific contentions regarding aggravation of his heart disorder by stress demonstrate actual knowledge of the elements of secondary service connection. Regarding VA's duty to assist, the Veteran's available service treatment records, VA treatment records, and reasonably identified private treatment records, have been obtained. The Veteran was also offered an opportunity to testify at a hearing before the Board, but he declined. Furthermore, the Veteran was provided with VA examinations in conjunction with the instant claims, and the Board finds that those VA examinations and medical opinions are sufficient for adjudicatory purposes. The examinations reflect comprehensive clinical findings, and the examiner's conclusions that the Veteran did not have a disorder that could be related to service are unequivocal, predicated on an accurate review of the record, and supported by a sufficient rationale. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. As VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating the claims for service connection for heart disease and a sinus disorder. Service connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). A veteran who served after December 31, 1946 is presumed to be in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. §§ 1111, 1137 (West 2002); 38 C.F.R. § 3.304 (2012). Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946 and certain types of heart disease manifest to a compensable degree within one year from date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (2012). For those exposed to such herbicides, service connection shall be presume for certain enumerated diseases, including ischemic heart disease. 38 C.F.R. § 3.309(e). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). As an initial matter, the Board notes that the Veteran's claimed exposure to herbicides has not been established in this case. The Board has reviewed the evidence submitted by the Veteran and obtained on his behalf, including command chronologies, and none of the evidence of record, other than the Veteran's lay statements, indicates that the Veteran was ever exposed to Agent Orange or any other herbicide, to include while cleaning planes. Indeed, the Veteran has not specifically alleged service in Vietnam, but rather, asserts that he was exposed to herbicides while serving aboard the USS Kearsarge, the USS Forrestal, and the USS Saratoga. To the extent that the Veteran has alleged direct herbicide exposure from cleaning planes that had flown in Vietnam and were contaminated with Agent Orange, the Veteran does not assert that he personally observed or handled any barrels of herbicides, and he has not presented any competent or scientific evidence to support his assertion of actual exposure. The Veteran is competent to testify that he cleaned planes; however, he is not competent to determine that the planes were covered in Agent Orange or any other herbicide. The Veteran has not identified any reason he believes planes he cleaned were contaminated with Agent Orange other than the fact that the planes came from Vietnam. There is simply no evidence that the Veteran had specific scientific knowledge such that he could identify Agent Orange residue by smell, sight, etc., and he has not claimed that he could. Nor does the evidence support herbicide exposure due to proximity to Vietnam. The Board notes VA's Compensation and Pension Service has identified a number of "blue water" Navy vessels that conducted operations on the inland "brown water" rivers and delta areas of Vietnam and certain other vessel types that operated primarily or exclusively on the inland waterways, which are now subject to the presumption of exposure to herbicides under 38 C.F.R. §§ 3.307 and 3.309. However, the USS Kearsarge, USS Forrestal, and USS Saratoga are not vessels recognized as having conducted "brown water" operations in Vietnam. Moreover, the Veteran has not submitted any evidence supporting that those ships would have operated in the rivers, delta areas, or inland waterways of Vietnam. Thus, consideration of exposure under the theory that his ships operated in close proximity to the shoreline, and therefore should be recognized as a "brown water" vessel, is not appropriate to the facts in this case. In sum, there is simply no competent evidence establishing that the Veteran was exposed to Agent Orange during his service. While the Veteran alleges the exposure occurred on a second-hand basis through contact with planes that had been in Vietnam, there is no provision of law establishing a presumption of such exposure. He is not qualified to identify Agent Orange compounds or to opine that such were on the specific planes that he cleaned, and there is no competent evidence establishing that planes he cleaned had any residuals of Agent Orange on them. An award of VA benefits may not be based on resort to speculation or remote possibility. See 38 C.F.R. § 3.102; see also Bostain v. West, 11 Vet. App. 124, 127 (1998). Accordingly, the preponderance of the evidence is against a conclusion that the Veteran was exposed to Agent Orange during service. The presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 are specifically limited to those individuals who were actually physically present in the boundaries of the Republic of Vietnam at some point during service. In this case, the Veteran does not claim nor do the records demonstrate that he physically visited or had duty in the Republic of Vietnam. Because the Veteran does not meet the criteria of having "service in the Republic of Vietnam" for purposes of 38 C.F.R. § 3.307(a)(6)(iii), his service connection claims must fail on the basis of the presumptive regulations. Heart Disease The Veteran contends that he suffers from a heart disorder manifested by chest pain that began in service or, alternatively, was caused or aggravated by his service-connected psychiatric disorder. The Veteran's available service treatment records are negative for evidence of heart disease. A July 1968 service examination is negative for heart abnormalities and blood pressure at that time was 108/60. Significantly, an echocardiogram (EKG) was negative. In August 1974, the Veteran had chest pain and dyspnea after striking his chest against a vice. A possible rib fracture and contusion were assessed, but no heart disability was diagnosed. A December 1974 service examination report shows that clinical evaluation of the heart, including an EKG, was within normal limits. Blood pressure at that time was 128/82. A June 1975 treatment note indicates a complaint of "check hypertension." Significantly, however, that note also indicates "error" and further, does not contain any identifying information as to whom the record belongs. In August 1978, the Veteran was evaluated for complaints of substernal chest pain. At that time, blood pressure was 124/78, heart sounds were normal, and diagnostic testing, including a chest x-ray and EKG, was within normal limits. No heart disorder was diagnosed. Thereafter, December 1980 and September 1982 service examinations were similarly negative for evidence of heart abnormalities, and blood pressure readings were 130/86 and 118/70, respectively. A December 1986 EKG report, presumably related to the Veteran's December 1986 service examination, shows a finding of sinus bradycardia but an otherwise normal study. Blood pressure at that time was 100/78. The available portion of the Veteran's December 1986 separation examination is silent for complaints or diagnoses relating to the heart. Post service Naval Hospital and private treatment records dated from April 1992 to November 1994 are negative for complaints or clinical findings related to hypertension or heart disease. Thereafter, VA treatment records show that in January 1996, the Veteran was admitted for complaints of chest pain and dyspnea thought to be angina pectoris. An EKG showed sinus bradycardia and mild left ventricle dysfunction, but physical examination of the heart was unremarkable. The hospital discharge summary states that, after observation, it became clear that the Veteran's complaints did not represent classical angina pectoris. It was noted that the Veteran underwent a stress test during which he achieved more than 85 percent of the maximum heart rate and had good exercise tolerance without any chest pains, arrhythmias, or angina pectoris. The physician noted that the Veteran's chest pains did not represent angina pectoris, but may be related to anxiety. The Veteran was afforded a May 1996 VA examination during which five blood pressure readings were within normal limits. The Veteran reported chest pains on and off with angina, for which he took nitroglycerin pills. An assessment was made of history of angina, atherosclerotic heart disease, on medication. Subsequent VA treatment notes show continued complaints of chest pain and associated cardiology work-ups. Significantly, a June 1998 VA treatment note shows that a May 1998 cardiolite stress test was within normal limits. In June 2000, graded exercise testing produced findings compatible with ischemic heart disease, but a subsequent August 2000 cardiolite stress test was negative. The Veteran continued to complain of periodic chest pains and carried a diagnosis of suspect for ischemic heart disease. He underwent several cardiology workups between June 2001 and June 2006, which were negative for evidence of ischemia or myocardial perfusion. In September 2006, a VA physician noted that the Veteran's non-exertional random chest pain may be more related to stress. It was noted that an August 2006 EKG was normal and that there was no objective evidence of coronary artery disease. It was further noted that the Veteran had undergone at least two nuclear medicine graded exercise tests, most recently in June 2006, which were negative for evidence of infarct or ischemia. Nevertheless, in January 2007, a VA treatment note indicates the Veteran to have atherosclerotic heart disease. Significantly, however, that treatment note also indicates that nuclear stress test and left ventricle ejection fraction were normal, and the provider's assessment does not include a diagnosis of heart disease. Most recently, the Veteran was afforded a VA heart examination in September 2012, during which the Veteran reported a history of chest pains in the precordium since the 1970s. He indicated that stress brings on the chest, but denied chest pain associated with exertion, nausea, or diaphoresis. He most recently had an episode of chest pain while driving. However, the chest pain resolved without nitroglycerin, which he was prescribed for use on an as-needed basis. The Veteran reported a hospitalization and extensive workup relating to his chest pain in 1996, however he had never been diagnosed with a myocardial infarction. Nor had he undergone surgery for his heart. The examiner noted the past diagnosis of chronic ischemic heart disease. Physical examination revealed a regular heart rhythm and normal heart sounds. Diagnostic testing, including an echocardiogram and holter monitor, was normal. The examiner also noted that a June 2006 myocardial perfusion test was negative for cardiac ischemia, and a June 2006 stress cardiolite test was negative for myocardial perfusion, ischemia, or infarction, and showed an enlarged left ventricle with normal left ventricle ejection fraction. The examiner noted the findings of an exercise METs test and an interview-based METs test, and further indicated a number of other factors affecting METs levels, including low testosterone, hypothyroidism, age over 50, elevated body mass index, chronic obstructive pulmonary disease, and musculoskeletal left-sided chest and upper arm pain. Based on the foregoing, the examiner found no objective findings of coronary artery disease. The examiner concluded that the past diagnosis of chronic ischemic heart disease was a misdiagnosis, citing to normal myocardial perfusion testing, a normal echocardiogram, and normal holter monitor. The examiner found that the Veteran's subjective symptoms of chest pain, dyspnea, and fatigue are at least as likely as not due to the Veteran's COPD, elevated BMI, hypothyroidism, and age. Therefore, the examiner found that a heart disability was less likely than not incurred in or caused by the service or the Veteran's service-connected anxiety disorder. Thus, the evidence in its entirety supports the conclusion that the Veteran does not have a heart disorder. In view of that, a basis upon which to establish service connection has not been presented. The Board acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the statements of the Veteran and his wife that the Veteran suffers from chest pain and heart problems. The Board notes that the Veteran and his wife are competent to report that the Veteran experiences chest pain. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). Indeed, the Board finds these reports of chest pain credible, as they are supported by the Veteran's medical treatment of record. However, the attribution of a diagnosis to a set of reported symptoms is a complex medical matter, requiring related expertise. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues); c.f. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (distinguishing situations in which a layperson is competent to identify the medical condition). Here, the Veteran has numerous cardiac evaluations and diagnostic studies of record. However, these evaluations ultimately did not support a finding of heart disease, with the most recent VA examiner concluding the prior diagnosis of ischemic heart disease was a misdiagnosis and not supported by the objective findings of record. The Board accords the September 2012 VA examination significant probative weight as it was based on a review of the claims file, physical examination of the Veteran, diagnostic testing, and was supported by rationale. Under the circumstances described above, the Veteran's appeal is denied. Sinus The Veteran maintains that he suffers from a chronic sinus disorder related to service. Available service treatment records show treatment for tonsillitis in January 1981 and an upper respiratory infection in March 1981. In June 1985, the Veteran reported to sick call with a complaint of sinus pain with purulent discharge. Sinus imaging at that time was within normal limits and the Veteran was assessed with a cold. The Veteran's entire December 1986 separation examination is not of record. However, the available portion of the examination report includes a notation that the Veteran had suffered from recurrent sinusitis over the last three years. Post service treatment records dated from April 1992 to November 1994 show treatment for an upper respiratory infection with pharyngitis in April 1993 but are negative for complaints or clinical findings of a sinus disorder. During a May 1996 VA nose and sinus examination, the Veteran reported recurrent post nasal drip with choking at night. He also reported that approximately three times per year, he experiences paranasal pressure headaches relieved with antihistamine decongestants. He also noticed some nasal obstruction and yellow mucus when infected. The Veteran reported a nasal fracture that was reduced while on active duty. Physical examination of the ears and oral cavity was within normal limits. The examiner noted developmentally absent frontal sinuses, but the rest of the sinus examination was within normal limits. A sinus series performed at the time of the examination revealed swollen nasal turbinates, but was otherwise negative. The VA examiner diagnosed probable recurrent acute sinusitis, with no evidence of chronic sinus disease at the time of examination. In a December 1997 statement, the Veteran argued that service connection for chronic sinusitis should be granted because medical evidence will show that the condition did exist. Significantly, the Veteran did not report current sinus problems, as he did with other disabilities discussed in that statement. Thereafter, in an October 2004 statement, the Veteran alleged VA treatment in December 1999 and December 2000, and private treatment in June 2001, March 2002, and September 2004, pertaining to his claimed "sinusitis with headaches." However, VA treatment notes dated from October 2000 do not show treatment for sinus complaints, and the Veteran did not submit corresponding records of the private treatment, despite VA requests to submit private records in support of his claim or authorizations for the release of the same to VA. See Olson v. Principi, 3 Vet. App. 480 (1992) (holding that VA's " 'duty to assist is not always a one-way street'; nor is it a blind alley," quoting Wood v. Derwinski, 1 Vet. App. 190, 193 (1991)). The Veteran was afforded July 2008 and June 2009 VA examinations relating to respiratory problems. Significantly, the Veteran did not mention any symptoms or treatment for sinus problems during those examinations. Private treatment records dated from August 2007 to August 2012 show the Veteran's reports of sinus problems. In August 2007, the Veteran reported a history of allergic rhinitis and sinusitis. However, during private treatment in April 2009, July 2009, August 2009, November 2009, April 2010, November 2010, ear, nose, and throat examination was normal. Then, in February 2011 and July 2011, the Veteran reported congestion, and in November 2011 a diagnosis was rendered of chronic sinusitis. In December 2011, the Veteran presented for private treatment, at which time he reported a chronic sinus infection. No diagnosis was offered, but the treatment note includes the following language written under the heading "TREATMENT PLAN/DISCHARGE MEDICATIONS:" "letterhead: [the Veteran] has progress[ive] severe COPD aggravated by chronic sinusitis [and] diabetes [without] complications. He is disabled due to the above diagnoses." Despite that notation, the only correspondence on the private provider's letterhead is undated and authored by the office coordinator, and indicates that the Veteran has been treated for diabetes, anxiety, and COPD, and due to his condition, was unable to work after July 2011. There is no discussion of sinusitis. Thereafter, ear, nose and throat examination in April 2012 was also normal. Most recently, the Veteran was afforded a September 2012 VA sinus examination, during which the Veteran reported a history of sinus difficulty beginning around 1976. He also stated that he had fractured his nose several times. He had not undergone any surgeries or nasal endoscopy for his condition, nor was he on any current sinus medications. He reported taking over-the-counter medication six months prior, but did not recall the name of the medication. Regarding symptoms, the Veteran reported post nasal drip and indicated that he wakes up at night coughing and choking. He also experienced choking during the day. The examiner noted a diagnosis of a sinus infection in service in June 1985, and a current diagnosis of dry nasal mucosa. Physical examination revealed dry nasal mucosa without epistaxis. Diagnostic testing showed clear sinuses and no objective findings of septal deviation, fracture, or chronic sinusitis. Based on the foregoing, the examiner diagnosed sinusitis that had resolved, noting that there were no objective findings of a chronic or ongoing sinusitis or previous fracture. The examiner also diagnosed dry nasal mucosa. The examiner opined that a nasal condition was less likely than not incurred in or caused by service, as service treatment records and current treatment records did not support a chronic or ongoing nasal condition of chronic sinusitis or dry nasal mucosa. After reviewing the evidence of record, the Board finds that service connection for sinusitis is not warranted. While the Veteran's service treatment records reflect a sinus complaint in June 1985, and a notation of sinus problems on a separation examination based on the Veteran's report, the most probative medical evidence of record fails to support the incurrence of a chronic sinus condition in service. Indeed, sinus imaging in service in June 1985 was negative, as was sinus imaging during VA examinations in May 1996 and September 2012. While private treatment records show a diagnosis of chronic sinusitis, that diagnosis appears to be based on the Veteran's reported history, as there is no correlating diagnostic evidence of sinusitis in support of that conclusion. Moreover, the May 1996 VA examiner diagnosed probable recurrent acute sinusitis, which is consistent with the conclusion that any episode of sinusitis is unrelated to the one that preceded it. This likewise fails to support the conclusion that the onset of a chronic disability occurred in service. To the extent that the Veteran himself contends that he suffers from such a condition, the Board does not find the Veteran's statement to be competent or credible. First, the Veteran is certainly competent to state that he has suffered from respiratory problems, which are susceptible to lay observation. The Veteran's contention that he suffers from a chronic, ratable condition, however, has not been corroborated by the objective medical evidence, and indeed, is contradicted by objective findings of record. Second, though the Veteran contends that he has suffered from sinus or breathing problems since service, the Board does not find this report to be credible. In this regard, treatment records dated prior to 2007 are essentially negative for treatment or complaints relating to sinus problems and significantly, the Veteran did not report chronic sinus problems upon treatment for respiratory symptoms in April 1994, or on VA respiratory examinations in July 2008 and June 2009. The Board finds it likely that, had the Veteran been experiencing chronic sinus problems, he would have reported it during those examinations. Thus, the Board finds that the Veteran's statements regarding continuity lack credibility. Even if the Board were to concede that he currently suffers from a sinus condition, service connection would still not be warranted on a direct or secondary basis. With respect to a direct basis, there is no evidence that the Veteran's claimed sinus condition is causally related to his active service. The only opinion of record addressing the etiology of his respiratory disorder finds that it is less likely than not related to service. That 2012 VA medical opinion is afforded great probative weight, as it was rendered after a complete review of the Veteran's claims file, including his service treatment records, examination of the Veteran, diagnostic testing, and it is supported by a sufficient rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). Moreover, the Veteran has not offered a medical opinion affirmatively linking his claimed sinus disorder to service. To the extent that the Veteran's statements could be read as providing such a causal link, the Board finds that he is not competent to offer such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Further, there is no competent evidence that the Veteran's claimed sinus condition is secondary to his service-connected COPD. Indeed, the December 2011 private treatment note indicates that the Veteran's COPD is aggravated by his claimed chronic sinusitis, and not the other way around. In summary, the Board finds that there is no competent or credible evidence that the Veteran currently suffers from a chronic sinus condition incurred in service, or secondary to a service-connected disability. Accordingly, the Board concludes that the criteria for service connection for a sinus disorder have not been met. Vision Disorder Additionally, the Veteran contends that he developed a vision disorder manifested by blurry vision and problems with depth perception that is related to service. Specifically, in written statements, the Veteran has reported difficulty drawing or cutting straight lines, determining how deep things are, and judging distance. Initially, the Board observes that astigmatism and other errors of refraction are not disabilities for which VA disability compensation benefits may be awarded. 38 C.F.R. §§ 3.303(c), 4.9 (2012). See also Norris v. West, 11 Vet. App. 219, 220 (1998). The evidence here pertaining to a vision disorder may be briefly stated. The Veteran's service treatment records show that, although the Veteran was noted to wear glasses during his January 1965 enlistment examination, no other eye abnormality was noted. Subsequent service treatment records show that the Veteran was seen on numerous occasions for eye complaints. A July 1969 service examination report documents bilateral refractive error correctable with lenses and further notes a diagnosis of right amblyopia. Amblyopia is an impairment of vision without a detectable organic lesion of the eye. Dorland's Illustrated Medical Dictionary, 53 (28th ed., 1994). The Veteran was again noted to be amblyopic in service in September 1977 and in September 1983. In November 1985, the Veteran failed a depth perception test, and in June 1986, he was again diagnosed with amblyopia. In post-service written statements, the Veteran has reported recurring problems with his vision, including difficulty with depth perception. Moreover, the Veteran is competent, as a lay person, to report both the onset and course of his vision symptomatology, as vision symptomatology is capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). Furthermore, the Board finds that the Veteran's reports are credible, as they are corroborated by his service treatment records showing numerous eye complaints and problems with depth perception and amblyopia. The Veteran was afforded a September 2012 VA eye examination during which a VA examiner diagnosed refractive error and noted that this sort of refractive error is characteristic of producing amblyopia. Based on the foregoing evidence showing an onset of a vision disorder diagnosed as amblyopia in service, in conjunction with the Veteran's current vision complaints, a basis upon which to establish service connection has been presented. In reaching this decision, the Board notes that a September 2012 VA examiner did not specifically diagnose amblyopia or relate amblyopia to service. However, the examiner did find that the Veteran's type of refractive error was productive of amblyopia, and further, did not indicate that the Veteran's chronic amblyopia shown throughout service had resolved. Moreover, the Veteran has competently and credibly reported continued problems with depth perception, which is a common characteristic associated with amblyopia. While the September 2012 VA medical evidence is not entirely supportive of the Veteran's claim, the totality of the evidence need not preponderate in favor of a claim in order to warrant an award of benefits. Rather, the evidence must preponderate against the claim to deny it. Where the evidence is equally balanced, the benefit of the doubt is given to the Veteran. Here, given the Veteran's current complaints regarding depth perception and the evidence that amblyopia and depth perception problems were first diagnosed in service, it cannot be reasonably concluded that the evidence preponderates against the claim. Accordingly, with the resolution of reasonable doubt in favor of the Veteran, service connection for amblyopia is granted. ORDER Service connection for a heart disorder is denied. Service connection for a sinus disorder is denied. Service connection for a vision disorder diagnosed as amblyopia is granted. REMAND A review of the record reveals that further development is needed prior to adjudication of the Veteran's headache and gastrointestinal claims. Regarding the Veteran's headache claim, the Board observes that the September 2012 VA examiner noted diagnoses of migraine headaches and tension headaches. The examiner found that the Veteran experienced a tension headache in service associated with ill-fitting glasses, which had since resolved. Regarding the diagnosed migraine headaches, the examiner opined that they are less likely as not related to service. In support of the opinion offered, the examiner stated that VA medical records and private medical records did not document a chronic or ongoing headache condition. The Board finds that the foregoing opinion is inadequate for rating purposes, as it is contradicted by evidence of record. Specifically, a private treatment note dated as early as May 1992 notes a report of occasional headaches, and VA treatment notes dated as early as January 1996 show complaints of chronic headaches. Moreover, Fioricet was prescribed for headaches in September 1996 and October 1997, and VA treatment notes dated from October 2000 to May 2007 generally show active medications to include prescription headache medicine. Furthermore, an August 2006 VA treatment note reflects a complaint of tension headaches. Given the evidence suggesting an ongoing headache condition, contrary to the VA examiner's conclusion, the Board finds that a new opinion is necessary. Additionally, the Board has a duty to consider all theories raised by the record. In an undated written statement, the Veteran reported that his headaches are related to stress and ringing in the ears. Therefore, on remand, the examiner should opine as to whether the Veteran's service-connected psychiatric disorder or tinnitus cause or aggravate any diagnosed headache disorder. Next, the Veteran contends that he has a gastrointestinal disability that is related to service. However, the record also raises the issue of entitlement to service connection for a gastrointestinal disability as secondary to service-connected psychiatric disability. In this regard, the Veteran reported a nervous stomach in January 1996, at which time he was assessed with rule out GERD. Additionally, in an October 2004 written statement, the Veteran reported that his stomach and esophageal symptoms were exacerbated by stress. Although a VA opinion was obtained in September 2012 indicating that the Veteran's currently diagnosed GERD is less likely as not related to service, no opinion was requested as to whether any current gastrointestinal disability was caused or is aggravated by his service-connected anxiety disorder. Therefore, remand is necessary for an opinion regarding entitlement to service connection for a gastrointestinal disability on a secondary basis. Accordingly, the case is REMANDED for the following action: 1. The RO should contact the Veteran and ask him to identify any additional sources of VA and non-VA treatment for his claimed gastrointestinal and headache disabilities. He is asked to provide, or authorize VA to obtain, any and all non-duplicative treatment records pertaining to these disabilities. Should the Veteran provide VA with a release to obtain private records, then at least two attempts to obtain those records should be undertaken unless it is made evident by the first request that a second request would be futile in obtaining such records, and all efforts to obtain these records should be documented in his claims folder 2. Then, notify the Veteran that he may submit lay statements from himself as well as from individuals who have first-hand knowledge of the onset and continuity of the symptoms of the claimed disabilities. He should be provided an appropriate amount of time to submit this lay evidence. 3. After associating any additional evidence with the claims file, the Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his claimed headache and gastrointestinal disabilities. With respect to any headache disability, the examiner should opine as to whether it is at least as likely as not that any diagnosed headache disorder is related to, or had its onset in service, or whether it is caused or permanently worsened by the Veteran's service-connected tinnitus or generalized anxiety disorder. The examiner should consider the evidence of an ongoing headache condition as shown by active VA prescriptions for medication to treat headaches. With respect to any gastrointestinal disability, the examiner should opine as to whether it is at least as likely as not that any diagnosed gastrointestinal disability, to include GERD, was caused or is permanently worsened by the Veteran's service-connected anxiety disorder. The claims folder should be reviewed, and such review should be reflected in the report provided. A complete rationale for any opinion expressed should also be provided. In offering these impressions, the Veteran's reports as to a continuity of symptoms should be discussed. If the examiner determines that a medically-sound opinion cannot be reached, it is requested that an explanation as to why that is so be included, to include a recitation of the missing facts necessary to render a non-speculative opinion. 4. Then readjudicate the appeal. If any benefit sought remains denied the Veteran should be issued an SSOC which addresses actions taken since the issuance of the last SSOC and given the opportunity to respond. The claim should thereafter be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs