Citation Nr: 1314374 Decision Date: 05/01/13 Archive Date: 05/15/13 DOCKET NO. 05-40 432 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to service connection for a chronic bilateral eye disorder. REPRESENTATION Appellant represented by: Vietman Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. I. Velez, Counsel INTRODUCTION The Veteran served on active duty from September 1961 to August 1962. He had additional duty in the Reserves and National Guard. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2005 rating decision of the Department of Veterans Affairs (VA), Providence, Rhode Island, Regional Office (RO). In July 2007, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. The case was previously remanded by the Board in December 2007, December 2010 and September 2011 for additional development. In November 2012, a Veterans Health Administration (VHA) specialist opinion was requested. The Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board has reviewed the Veteran's Virtual VA file and finds that there are no additional records relevant to the present claim. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. There is clear and unmistakable evidence that the Veteran's esotropia and amblyopia pre-existed entrance to active duty. 2. There is clear and unmistakable evidence that the Veteran's esotropia and amblyopia did not permanently increase in severity beyond the natural progression of the diseases in service. 3. Esotropia is a defect which is not subject to service connection; and there is no evidence of superimposed eye injury or disease in service. 4. The evidence of record preponderates against a finding that the Veteran has a vision disorder that had its onset in or is otherwise related to her military service. CONCLUSION OF LAW A vision disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a July 2007 letter, sent prior to the initial October 2005 rating decision, advised the Veteran of the evidence and information necessary to substantiate his service connection claims, as well as his and VA's respective responsibilities in obtaining such evidence and information. A March 2006 letter advised the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the March 2006 letter did not predate the rating decision, as the claim is being denied, the timing error is harmless. Moreover, the claim was subsequently readjudicated in Supplemental Statements of the Case of November 2009, March 2011 and August 2012. Relevant to the duty to assist, the Veteran's service treatment and personnel records, and VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. The Board has also reviewed the Veteran's paperless Virtual VA claims file, a highly secured electronic repository that is used to store and review documents involved in the claims process, and has noted that there are no additional documents in the Virtual VA file not already contained in the paper claims file. Additionally, he was afforded VA examinations in April 20089, October 2009, and February 2011, and a clarification medical opinion was obtained in October 2011. A VHA specialist opinion was also obtained. The medical evidence as a whole is sufficient and adequate to decide the claim. In particular the VHA specialist's opinion was based on a review of the claim file and the records contained therein to include prior VA examinations. The specialist offered clear conclusions with supporting data as well as a reasoned medical explanations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge clarified the issue on appeal and elicited testimony about the etiology of the Veteran's eye conditions. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Legal Criteria and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. A Veteran is considered to have been 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 and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Only such conditions as are recorded in examination reports are considered as noted. 38 C.F.R. § 3.304(b). History of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 03- 2003; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In deciding a claim based on aggravation, after having determined the presence of a pre-existing condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether this constitutes an increase in disability. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. 1153; 38 C.F.R. 3.306. Temporary or intermittent flare-ups of the pre-existing condition during service are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247- 48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Accordingly, "a lasting worsening of the condition" -- that is, a worsening that existed not only at the time of separation but one that still exists currently -- is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Active service includes any period of active duty for training (ACDUTRA) during which the individual was disabled from a disease or an injury incurred in the line of duty, or a period of inactive duty training during which the veteran was disabled from an injury incurred in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Further, ACDUTRA includes full-time duty in the Armed Forces performed by the Reserves for training purposes. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Inactive duty training includes duty, other than full-time duty, prescribed for the Reserves. 38 U.S.C.A. § 101(23)(A). Reserves includes the National Guard. 38 U.S.C.A. § 101(26), (27). Congenital or developmental defects are not diseases or injuries within the meaning of the applicable legislation. See 38 C.F.R. § 3.303(c) , 4.9 (2012); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). VAOPGCPREC 82-90 (July 18, 1990) (a reissue of General Counsel opinion 01-85 (March 5, 1985)) in essence held that a disease considered by medical authorities to be of familial (or hereditary) origin by its very nature preexists a claimant' s military service, but could be granted service connection if manifestations of the disease in service constituted aggravation of the condition. Congenital or developmental defects, as opposed to diseases, could not be service-connected because they are not diseases or injuries under the law; however, if superimposed injury or disease occurred, the resultant disability might be service-connected. Id. VA regulations provide that refractive errors of the eyes are not diseases or injuries within in the meaning of applicable legislation for disability compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9 (2012); see also Winn v. Brown, 8 Vet. App. at 516. Myopia is a refractive error also called nearsightedness. Dorland's Illustrated Medical Dictionary 1094 (28th ed. 1994). Presbyopia is a visual condition that becomes apparent especially in middle age and in which loss of elasticity of the lens of the eye causes defective accommodation, and inability to focus sharply for near vision. McNeely v. Principi, 3 Vet. App. 357, 364 (1992). Presbyopia is "hyperopia and impairment of vision due to ... old age." Dorland's Illustrated Medical Dictionary 1349 (28th ed. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service treatment records show that an October 1961 physical examination done for entry into active duty, was completely negative for any eye condition. Distant vision was noted to be 20/70 correctable to 20/20 on the right eye and 20/400 on the left eye correctable to 20/50. The accompanying report of medical history shows the Veteran noted prior eye trouble and using glasses. No further details were provided in the report regarding his previous eye troubles. Service treatment records further show that the Veteran was treated by military medical personnel for esotropia and squamous blepharitis in February 1962. The report of the Veteran's June 1962 Army physical examination for release from active duty relates that he was advised to undergo an eye operation during active service that was not performed. Upon examination at the time of separation his uncorrected visual acuity was 20/80 in the right eye, correctable to 20/20, and 20/200 in his left eye, correctable to 20/30. It was noted he wore glasses. He was further noted to have hyperopia, astigmatism, esotropia, and amblyopia of the left eye. Post service, a March 2008 signed statement from Dr. A.R.Cote, an eye physician and surgeon, notes the Veteran suffered a Chemical corneal burn "OU" (in both eyes), in 1998 that required conjunctival grafting. Since then, he noted, the Veteran had substantial ocular surface disease. He further noted that he recently had a cataract extraction with intraocular lens implants. Most recently, the ocular pressure was found to be elevated and he required ocular medication. The Veteran underwent VA examinations in April and October 2009, and February 2011. All the examinations were conducted by the same examiner. In April 2009, the examiner diagnosed the Veteran with pseudophakia of both eyes; amblyopia of the left eye secondary to strabismus; and a corneal scar of the right eye with pannus secondary to a chemical injury that occurred approximately seventeen years earlier. The examiner noted the Veteran's visual acuity at the time of his entry and release from active duty and stated that, in summary, the Veteran had a bilateral refractive condition going on active duty with amblyopia in the left eye and had a refractive condition with amblyopia in the left eye on release from active duty in 1962. The October 2009 VA examination report reflects that the diagnosed pseudophakia of both eyes was an artificial lens implantation. The examiner stated that the strabismus amblyopia was congenital, and unrelated to the Veteran's active or inactive duty. The VA examiner also diagnosed mild corneal pannus of the left eye secondary to the chemical burn seventeen years earlier; and glaucoma of the right eye, unrelated to active or inactive duty. However, the examiner did not provide an opinion as to whether all of the Veteran's diagnosed eye disorders were casually related to his military service; nor was a rationale provide in support of those opinions that certain conditions were unrelated to the Veteran's active or inactive duty. In February 2011, the Veteran underwent a new VA eye examination conducted by the same optometrist who performed the 2009 examinations. Upon clinical evaluation, the examiner diagnosed the Veteran with glaucoma of the right eye; pseudophakia of both eyes; corneal scar nasally along with mild corneal pannus in the right eye; and, amblyopia of the left eye. The VA examiner opined as to the etiology of these disabilities, including the current glaucoma of the right eye, pseudophakia in both eyes, and corneal scarring in both eyes, that the disabilities were not incur during nor were they subsequently aggravated (beyond its natural progress) in the Veteran's service. The VA examiner also found that the amblyopia in the Veteran's left eye was caused by deprivation of vision during the Veteran's early childhood, and not during the period of active duty for training. However, no opinion was proffered as to whether the amblyopia was aggravated beyond its normal progress during service. In an October 2011 addendum, the VA examiner noted that he examined the Veteran in 2009 and 2011 and reported his visual acuity at entry and separation from service when diagnoses were rendered of hyperopia, astigmatism, esotropia, and amblyopia, left eye. The VA examiner said that "in summary" the Veteran's amblyopia of the left eye was not aggravated by his military service, including that from September 1961 to August 1962". Unfortunately, the examiner did not provide a rationale for his opinion. A VHA specialist medical opinion was obtained in December 2012. The specialist stated that nothing done to the Veteran's left eye at age 24 or 25 could have either aggravated or improved his vision in the left eye. That would include medical treatment, surgery, or anything which may have happened during active duty. He diagnosed the Veteran with amblyopia of the left eye, esotropia of both eyes, bilateral pseudophakia caused by the necessity to have a cataract surgery, corneal scarring with panus in the right eye, iris atrophy in the right eye, and open angle glaucoma of the right eye. Regarding the esotropia of the eyes, he explained that it is a condition present at birth or which develops shortly after birth and since the in-turning of the eyes would cause two different images to fall on the retina, the youthful person will select one eye to see well with and suppress the other eye to avoid this double vision. What happens after an extended period of suppression of one eye, is the development of amblyopia ex anopsia. By age 24 or 25, the amblyopia is permanent and will not change to any great extent later in life regardless of whether the eyes are straightened as an adult, or occlusion therapies attempted as an adult, or any other treatment is attempted. The amblyopia will stay about the same level as it has reached and would not be affected by anything else that would occur in the normal active duty service. He further noted that only a subsequent injury or infection or other medical problem in the amblyopic eye would cause deterioration beyond normal status. He noted there is no evidence that any such injury or illness of significance occurred during the Veteran's active duty career. Regarding the amblyopia, he opined that it was a lifelong problem starting at early youth if not at birth and was due to the in-turning of the eyes, esotropia, and neither of these conditions have anything to do with the Veteran's active duty from 1961 to 1962, nor were any of them aggravated by active duty. Regarding the bilateral cataracts, he stated that their development at age 71 is totally unrelated to his active duty from 1961 to 1962. Therefore, the pseudophakia, the implant of an intraocular lens to replace the lens which was removed because of cataracts, would have no relationship to anything which occurred during active duty. The development of cataracts at age 71 is an age related phenomenon, possibly altered by genetics and inheritance, but not related to active duty. Regarding the corneal scarring, he opined that it was most likely due to the cataract surgery which he believes had complications which is evidenced by the iris atrophy. However, the left eye cataract surgery appears to have had no complications. Regarding the open angle glaucoma of the right eye, he also believes it is due to the complications of the cataract surgery of the right eye and is totally unrelated to active duty. He noted that the Veteran stated that the increased intraocular pressure and the decrease in vision in the right eye was noted since the cataract surgery. The specialist further noted that the Veteran injured both of his eyes in an industrial accident with burns to both eyes from a chemical burn in 1992 at age 55. Anything that developed from that accident, for example cataracts or open angle glaucoma in the right eye, or the presence of corneal scarring and panus in one eye might very well be related to this non-service connected accident. In summary, he opined that the esotropia and amblyopia affecting the left eye were present form early youth and were not caused by anything that happened during the period of active duty form 1961 to 1962, nor were any of these conditions increased in disability beyond the natural progress of the disorder during the Veteran's period of active service. The cataracts which developed later on in life, the pseudophakia that resulted from the cataracts surgery, the open angle glaucoma in one eye which developed following cataract surgery, the corneal scarring and panus formation and the iris atrophy, which is related to the cataract surgery in the right eye, all are totally unrelated to active service. Finally, he opined that esotropia is congenital and that it is a defect. And, even if anyone wants to call it a disease, it would not increase in severity nor is it the subject of superimposed disease or injury during active military service that resulted in any additional disability. At the outset, the Board notes that the VHA advisory opinion was obtained as the Board found that the April and October 2009, the February 2011 VA examinations, and the October 2011 addendum opinion were inadequate to render a decision. Indeed, the examiners failed to provide an adequate rationale for the opinions provided therein. The Court has held that held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In other words, an examination that provides an etiology opinion without a rationale is inadequate. The Court has further held that once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, the Board affords little probative weight to those examinations and opinions. Having so determined, the Board is left with the VHA specialist's opinion. Considering the competent and reliable evidence of record, the Board finds that the evidence is against a grant of service connection for all of the eye conditions the Veteran has been diagnosed with including, amblyopia of the left eye, esotropia of both eyes, bilateral pseudophakia caused by the necessity to have a cataract surgery, corneal scarring with panus in the right eye, iris atrophy in the right eye, and open angle glaucoma of the right eye. Regarding the esotropia and amblyopia of the eyes, the Board finds that there is clear and unmistakable evidence that the Veteran's esotropia and amblyopia did not permanently increase in severity beyond the natural progression in service. Indeed, the specialist stated that the esotropia exists either at birth or shortly thereafter and that the amblyopia results from the esotropia early in life. As such, the Board concludes that there is clear and unmistakable evidence that the Veteran's esotropia and amblyopia existed prior to service and were not aggravated by service. Consequently, the presumption of soundness has been rebutted and the Veteran's esotropia and amblyopia pre-existed service. The December 2012 specialist was clear in that esotropia is a condition present at birth or developed shortly thereafter. Regarding the amblyopia, he was clear in explaining the development of the amblyopia as a result of the esotropia and how nothing in service would aggravate the condition aside from an injury or illness affecting the eye which was not shown in service. Therefore, he explained that nothing occurring in active duty would worsen the conditions. Accordingly, the Board finds that, based on the competent and probative evidence of record, the Veteran's pre-existing esotropia and amblyopia were not aggravated by his military service. Furthermore, as noted above, congenital defects cannot be service connected. The specialist stated that esotropia is a congenital defect and as such, it is not service connectable. Regarding the remaining diagnosed eye conditions, bilateral pseudophakia caused by the necessity to have a cataract surgery, corneal scarring with panus in the right eye, iris atrophy in the right eye, and open angle glaucoma of the right eye, he described how each condition is developed. The cataracts are age related and lead to the pseudophakia. Moreover, the corneal scarring , open angle glaucoma and iris atrophy, he opined, are all related to the cataract surgery. He reasoned, that the cataracts occurred late in life and are age related. If not age related, then they are related to the chemical burns to the eyes in 1992. The remainder of the eye conditions are a consequence of the cataracts and the surgery for the same. The specialist was thorough in explaining each condition and the possible causes, and why he believed that the conditions were not related to service in any way. Accordingly, the Board finds that the competent and reliable evidence of record shows the eye conditions are not related to service. The Board acknowledges that the Veteran has argued that his visual acuity worsened prior to discharge from service and that this worsening of vision in service, caused further deterioration of his vision and necessitated his subsequent treatment for glaucoma, cataract surgery and macular degeneration. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet.App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's eye disorders and his military service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, while the Veteran is competent to describe his treatment for eye disorders, and the observable symptoms, the Board accords his statements regarding the etiology of such disabilities little probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). (CONTINUED ON NEXT PAGE) In sum, the Board finds that the competent and reliable evidence of record shows that there is clear and unmistakable evidence that the Veteran's esotropia and amblyopia preexisted service and were not aggravated beyond their natural progression by service. Moreover, the bilateral pseudophakia caused by the necessity to have a cataract surgery, corneal scarring with panus in the right eye, iris atrophy in the right eye, and open angle glaucoma of the right eye, were not caused by or aggravated by service. Accordingly, service connection for an eye condition is denied. ORDER Service connection for an eye condition is denied. ____________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs