Citation Nr: 1318319 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 10-10 569 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a traumatic brain injury (TBI), to include memory loss and mood swings as separate cognitive defects. 2. Entitlement to service connection for a vision disorder resulting in eye surgery and decreased night vision (claimed as a vision condition). 3. Entitlement to service connection for an acquired psychiatric disorder other than service-connected mood disorder. ATTORNEY FOR THE BOARD B. R. Mullins, Counsel INTRODUCTION The Veteran had active service from July 2006 to November 2007 and he had additional active duty for training (ACDUTRA) from March 16, 2004, to July 2, 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, denying the issues currently on appeal. The issues currently on appeal were previously remanded by the Board in May 2012. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claim. A review of the documents in said file reveals that they are duplicative of the physical evidence in the paper claims file. As an introductory matter, the Board notes that the Veteran is seeking service connection for PTSD. He is already service-connected for a mood disorder. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that a claimant seeks service connection for the symptoms of a disability, regardless of how those symptoms are diagnosed or labeled. Therefore, the Veteran is essentially seeking service connection for a disability manifested by symptomatology that is separate and distinct from his already service-connected mood disorder. The issue has thus been restated on the title page of this decision. The issue of entitlement to service connection for an acquired psychiatric disorder other than service connected mood disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence is in relative equipoise on the material issue of whether the Veteran sustained a traumatic brain injury as the result of exposure to an improvised explosive device during service. 2. The Veteran does not suffer from a disability associated with his impaired vision that manifested during, or as a result of, active military service; his refractive error of the eyes was not aggravated by military service as a result of superimposed disease or injury. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a traumatic brain injury and residuals thereof have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1154(b), 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for establishing entitlement to service connection for a vision disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 4.9 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has a duty to notify and assist veterans 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 Veteran 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 Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). 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). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. A letter sent to the Veteran in January 2009 addressed all notice elements listed under 3.159(b)(1) and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received numerous VA medical examinations in conjunction with his claims, and VA has obtained these records as well as the records of the Veteran's outpatient treatment with VA. In particular, the Board finds that the January 2009 VA eye examination is adequate as the examiner reviewed the claims file, considered the contentions of the Veteran, examined the Veteran, and provided a rationale (lack of physical findings) for the inability to provide a nexus opinion. Additionally, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for fair adjudication of the claim that has not yet been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Additionally, the Board finds there has been substantial compliance with its May 2012 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). The record indicates that the Appeals Management Center (AMC) readjudicated the issues on appeal based on all of the evidence of record. The AMC later issued a Supplemental Statement of the Case (SSOC). Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To establish service connection, there must be: (1) evidence of a current disability; (2) evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a veteran has served for 90 days or more during a period of war, or during peacetime service after January 1, 1947, and a chronic disorder, such as psychoses, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in 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. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 (2012). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be 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, 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"). Residuals of TBI The Veteran contends that he is entitled to service connection for the residuals of a traumatic brain injury (TBI). Specifically, the Veteran asserts that he sustained a TBI during an improvised explosive device (IED) detonation in 2006. Service treatment records confirm that the Veteran's vehicle was involved in an IED blast in December 2006. The Veteran complained of a headache and right lower back pain. Examination revealed the Veteran to be fully alert and oriented and in no apparent distress. There was a small laceration above the left eye, but the Veteran's pupils were equal and reactive to light. The Veteran also denied any loss of consciousness. The Veteran was assigned to quarters for 24 hours. In his September 2007 post-deployment health assessment, the Veteran reported that he continued to have headaches. Service connection has since been established for headaches. He also reported that he experienced dizziness, fainting or light-headedness during service, but that he no longer experienced these symptoms. The Veteran was not diagnosed with, or treated for, a TBI during active duty. The record contains a magnetic resonance image (MRI) of the brain performed upon separation from active duty in December 2007. It was noted that the Veteran had a history of prior trauma and that he was presently complaining of headaches. No focal brain parenchymal abnormalities were found upon evaluation. The record also contains a general VA examination report dated December 2007. It was noted that there was no history of memory loss, poor coordination, vision loss or speech difficulty. The Veteran did endorse a history of headaches. The examiner concluded that the Veteran's headaches were secondary to chronic sinusitis that manifested during military service. The Veteran denied any interpersonal relationship difficulties, depression, panic attacks, loss of control, anxiety or confusion at this time. A neurological examination also revealed normal coordination, normal orientation, normal memory and normal speech. The Veteran underwent a TBI evaluation in August 2008. It was noted that he had not lost consciousness and that he had no incident of disorientation or confusion. There was also no amnesia at the time of the incident or any post-traumatic amnesia. The report also reflects that the Veteran had not been told he was acting differently. There were no neurobehavioral symptomatology, aside from poor concentration, forgetfulness, slowed thinking, feeling anxious or tense, feeling sad or depressed, irritability and poor frustration tolerance. The Veteran reported exposure to 3 significant explosion incidents, all detonating within 5 feet of his vehicle. The Veteran reported that he did not know whether he lost consciousness during the first explosion, but "he did fine" in the other 2 explosions. It was determined that the findings were consistent with a TBI. However, it was noted that further cognitive evaluation would be beneficial. The Veteran was afforded a VA TBI examination in January 2009. It was noted that he had a history of head trauma, without loss of consciousness, while in the military when the vehicle he was riding in was hit by an IED. The Veteran had no amnesia, neurological deficits or psychiatric symptoms. His only complaint at the time was headaches and he was prescribed Motrin and placed on quarters for 24 hours. The examiner concluded that the Veteran did not fulfill the criteria for TBI since there was no loss of consciousness, psychiatric symptomatology, neurological deficits or amnesia. There was no history of dizziness or vertigo, balance and coordination problems, pain, autonomic dysfunction, numbness, paresthesias or other sensory changes such as weakness or paralysis. The Veteran also did not exhibit mobility problems, fatigue, malaise, bowel or bladder problems or erectile dysfunction. There was also no history of hearing loss or tinnitus, hypersensitivity to light or sound, vision problems, difficulty with speech or swallowing, decreased sense of taste or smell, endocrine dysfunction or cranial nerve dysfunction. A January 2009 VA polytrauma case manager note indicates that neuropsychological testing revealed cognitive and personality changes. There were observed deficits in memory, attention, anger management, problem solving and judgment, as well as poor academic performance. According to a June 2009 VA neuro-psychology note, results of a neuropsychological screening supported a diagnosis of TBI. It was noted that the results strongly supported a mood change due to TBI, as opposed to major depressive disorder. The Veteran's symptoms were noted to be abnormal sleep patterns, isolation, depressed mood, feelings of worthlessness, poor concentration, poor attention span, anhedonia, low self esteem and frequent forgetfulness. The Veteran was afforded another examination with the examiner that performed the January 2009 examination in August 2009. The examiner noted that it was previously determined that the Veteran did not meet the criteria for TBI, since he only complained of left shoulder pain, low back pain, ringing in the ears and decreased hearing following the December 2006 incident. There was also no history of dizziness, vertigo, seizures, balance and coordination problems, or problems with numbness, paresthesias or other sensory changes. There was also no weakness or paralysis and no motility problems. The Veteran did not experience fatigue, malaise or cranial nerve dysfunction. There was also no history of bowel or bladder problems, erectile dysfunction, speech or swallowing difficulty, a decreased sense of taste or smell or endocrine dysfunction. However, it was also noted that there was no history of tinnitus, hearing loss or vision problems. Testing did reveal a mild impairment of memory, attention, concentration or executive functions resulting in mild functional impairment. There was also mildly impaired judgment and the Veteran was occasionally disoriented. Motor activity was normal and visual spatial orientation was normal. The examiner then concluded that despite the absence of symptom criteria for TBI described in service after the IED blast, the presence of abnormal brain single-photon emission computed tomography (SPECT) along with the symptomatology described and the neuropsychological examination suggested that the most likely explanation of his symptoms and findings was TBI. The Veteran underwent VA neuropsychological testing with VA in May 2010. The Veteran reported that he failed his college courses and subsequently had to quit school. He also described emotional "numbness" and fluctuations in mood. It was noted that the Veteran was previously prescribed a mood stabilizer, but the Veteran felt that it did not work and he was not willing to try it again. It was also noted that the Veteran had a prior history of a traumatic head injury as a child. However, following this incident, he had excellent academic achievement. The Veteran was prone, however, to minimize his symptomatology and he was hesitant to engage in treatment. The Veteran reported that he quit college because the academic load was too much for his current cognitive functioning. He also reported memory problems but felt that this was slightly better. He indicated that one month earlier, he only had one or two good days. Now, however, he only described one bad day a week on average. The Veteran also described angry outbursts but that these were calmer than they were in the past. He had decreased his alcohol consumption, although he indicated that alcohol helped him sleep and his sleep was now impacted since lessening his intake. He also described visual problems, especially at night, complaining of blurry vision and sensitivity to light. The Veteran had laser eye surgery and his doctor told him that everything went fine. The Veteran also described an inability to find meaning or emotions in things that happened around him and that he was unable to establish another relationship since his girlfriend broke up with him. The examiner noted that the Veteran was a difficult patient to evaluate, as he was not very cooperative with the assessment process. He was prone to give up very easily and he was frequently irritable. It was also noted that on the one hand the Veteran reported that he was doing well yet he also admitted to continuous memory problems, irritability and concentration problems. The Veteran was deemed to have good hygiene and he was responsive and alert throughout the evaluation. He had a depressed affect with problems with mood, energy, sexual drive, pleasure, sleep, helplessness and hopelessness. There was no evidence of a thought disorder. The Veteran did report feeling strange around his friends because he felt he was different. The Veteran's insight regarding his situation was deemed to be poor, but his judgment was fair. A brain MRI from December 2007 was reviewed and it revealed no focal brain parenchymal abnormalities. A brain SPECT from September 2008 indicated that there was scintigraphic evidence of hypoperfusion/hypometabolism involving the frontal and temporal lobe cortices bilaterally. These findings had been described in patients with TBI. The examiner noted that the Veteran reported that his problems started when he was exposed to several blast episodes resulting in periods of confusion and altered consciousness. Testing revealed a significant cognitive decline. The Veteran's scores revealed visual organization problems, visual memory and concentration problems. The Veteran was diagnosed with a mood disorder due to his general medical condition (post-concussion syndrome) and alcohol abuse. The Veteran was most recently afforded a VA examination for his claimed TBI in December 2012. The Veteran reported that while he was in Iraq, he was involved in three IED explosions. The examiner noted that only one of these was documented in the records. The Veteran denied losing consciousness at this time but that he may have been briefly disoriented. The Veteran also reported extreme low back pain, shoulder pain and headaches due to his three IED explosions. The examiner discussed in detail the Veteran's medical history since his separation from active duty, and upon examination, concluded that the Veteran did not suffer from a TBI that was incurred in or caused by an injury during military service. The examiner explained that there was only evidence of medical attention following one explosion and the Veteran did not lose consciousness as a result of this incident. While a prior VA examiner concluded that there was evidence of TBI following a SPECT scan and neuropsychological testing, the examiner explained that these findings were non-specific and could be associated with depression or alcohol abuse. The Veteran was suffering from alcohol abuse at the time of this study, which likely had a negative effect on his neuropsychological testing. Poor cooperation likely also had an impact. Also, depression can diminish cognitive performance. Cognitive testing performed as part of this examination was also not compatible with more than mild or no cognitive impairment. However, the examiner did concede that this testing was not nearly as extensive as formal neuropsychological testing. Nonetheless, psychiatry notes indicate that the Veteran symptoms would wax and wane depending on his medication compliance and alcohol intake. The Veteran also suffered his injury in December 2006 and continued to serve on active duty until October 2007. The records revealed no evidence of treatment for headaches or other sequelae of possible TBI, nor did they show evidence of a change in personality or a decline in performance, such as he is manifesting now. The examiner also discussed the head injury the Veteran sustained as a child, but concluded that there was no evidence of behavioral or cognitive sequelae following this injury. As such, the examiner felt that this injury was not germane to the issue at hand. Regarding the Veteran's frontal lobe dysfunction, the examiner explained that this may be part of other conditions such as depression and alcohol abuse. Frontal lobe syndromes can be "disinhibitory," like the effects of alcohol. Moodiness, impulsivity, irritability, and sleep disturbance are also associated with depression and alcohol abuse. The neuropsychiatric testing of record did not specify frontal lobe dysfunction, but more of a global decline. An element of the examination thought to be sensitive to frontal lobe function was normal. Also, the Veteran's behavior during the present examination was entirely appropriate with nothing to suggest frontal lobe dysfunction. He was also well-groomed, engaged in the process and attentive. This also did not suggest frontal lobe dysfunction. As such, the examiner opined that the Veteran's frontal lobe dysfunction was mild and part of the overall cognitive decline associated with his other conditions. The record contains favorable and unfavorable medical opinion evidence on whether the Veteran sustained a traumatic brain injury as the result of exposure to an improvised explosive device during service. The Board must therefore weigh the credibility and probative value of these opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board finds the favorable medical opinion evidence and the unfavorable medical opinion evidence both to be credible and persuasive. As explained by the December 2012 VA examiner, the Veteran denied losing consciousness during the documented IED detonation while on active duty. A review of the Veteran's service treatment records confirms this fact. Upon examination and review of the Veteran's medical history (both during and after military service), the examiner determined that the Veteran did not currently suffer from the residuals of a TBI. The examiner explained that the Veteran was able to complete military service without incident and that his more recent symptoms and cognitive decline were not present following the in-service injury. Therefore, the examiner related the Veteran's diminished cognitive decline to depression and alcohol use. The Board is cognizant that service connection is in effect for a mood disorder. The January 2009 VA examiner was also of the opinion that the Veteran did not meet the criteria for a diagnosis of TBI due to the fact that he did not lose consciousness and that he did not exhibit symptoms such as neurological deficits or mobility problems. The examiner's opinion, however, changed in August 2009 after reviewing an abnormal SPECT scan and considering this evidence in conjunction with the symptomatology described and the neuropsychological examination. The December 2012 examiner also discussed in great detail the SPECT findings but found that they were non-specific and "can be associated with depression, for which [the Veteran] is already service connected, and alcohol abuse, from which he was suffering at the time of the study." The December 2012 examiner, however, conceded that cognitive testing performed as part of this examination was not as extensive as neuropsychological testing previously performed, but maintained that the examination revealed no more than mild to no cognitive impairment in December 2012. Also, the December 2012 examiner noted that the severity of the Veteran's symptoms had waxed and waned since military service due to medication compliance and alcohol intake. An August 2008 TBI evaluation report also reflects that findings were consistent with TBI and a June 2009 VA neuropsychology note indicates that the results were strongly supportive of a mood change due to TBI. The August 2008 evaluation report indicates that the Veteran exhibited symptomatology consistent with a concussion as a result of his in-service injury. The Veteran clearly presents with a very complicated clinical picture. The above favorable and unfavorable medical opinions were derived after extensive review of the Veteran's medical history and examination, and based on sound medical principles. Hence, the Board finds that the evidence in favor of the claim is equally balanced with the evidence that is against the claim. Accordingly, the Board resolves reasonable doubt in the Veteran's favor and grants entitlement to service connection for TBI and residuals thereof. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Vision Condition The Veteran contends that he is entitled to service connection for a disability manifested by impaired vision. However, as outlined below, the evidence of record demonstrates that the Veteran has suffered from a visual defect since he was a child. The preponderance of the evidence of record demonstrates that no additional disability has been superimposed on this visual defect as a result of active military service. As such, service connection cannot be established. According to the Veteran's November 2003 enlistment examination report, he had uncorrected distant vision of 20/200 bilaterally. He was noted to be suffering from defective vision at this time, and the record reflects that the Veteran had worn corrective lenses since the age of 12 due to difficulty in seeing distant objects. A September 2006 pre-deployment examination report also reflects that the Veteran wore prescription glasses. Service treatment records reflect no complaint of worsening vision or additional defect, aside from the treatment of conjunctivitis in April 2004. The evidence of record suggests that this was an acute and transitory condition, as there is no evidence of continued treatment or any permanent disability noted on the Veteran's post-deployment health assessment. As such, there is no evidence of an additional disability to the eyes during active military service. The record contains a general VA examination report dated December 2007. It was noted that the Veteran had decreased visual acuity in the left and right eyes. The Veteran had been wearing eyeglasses since he was 8 years of age and he was now wearing contact lenses. According to an October 2008 VA outpatient treatment record, a neuropsychological evaluation suggested visuospatial deficits as well. The Veteran was afforded a VA eye examination in January 2009. It was noted that the Veteran had refractive surgery to both eyes in 2008. The Veteran reported night visual disturbances since December 2007. The Veteran denied any ocular pain. The Veteran was diagnosed with LASIK surgery. The examiner explained that although night vision symptoms can be secondary to LASIK surgery, the Veteran indicated that his symptoms began prior to the surgery in December 2007. Also, no physical findings were observed that could explain the Veteran's claimed symptoms. Therefore, the examiner was unable to resolve this issue without resort to mere speculation. The Veteran was seen for neuropsychiatric testing in May 2010. He described visual problems, especially at night, complaining of blurry vision and sensitivity to light. The Veteran reported that he had laser eye surgery and that his doctor told him that everything went fine. The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for a vision condition. Initially, the Board notes that the evidence of record demonstrates that the Veteran has been wearing glasses since he was a child due to decreased visual acuity. This was noted on the Veteran's National Guard enlistment examination. Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Congenital or developmental "defects," such as refractive error of the eyes, are generally precluded from being service-connected because such "defects" are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; accord Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). However, a congenital defect can still be subject to superimposed disease or injury. VAOPGCPREC 82-90. If such superimposed disease or injury does occur, service connection may be warranted for the resulting disability. Id. The record contains no objective evidence of any additional disability. While the Veteran did report night visual disturbances since December 2007 during his VA examination, the examiner did not observe any physical findings that would explain the Veteran's reported symptoms. There is no objective evidence of injury or additional disability to the eyes or a worsening of the Veteran's vision during military service. As such, there is no objective evidence of a superimposed disease or injury and service connection is not warranted. The Board recognizes that the Veteran believes his reported symptoms are related to his being in the proximity of an improvised explosive device (IED) while in Iraq. The Veteran did not complain of visual complaints at the time of this incident and his pupils were found to be equal and reactive to light. In fact, the Veteran did not complain of impaired vision for the remainder of his military service. During the December 2007 VA examination, the only symptomatology associated with the eyes was decreased visual acuity - a defect for which service connection cannot be established. The record contains no evidence to demonstrate that the Veteran has the requisite training or expertise to relate current subjective symptomatology to an IED explosion that occurred in 2006. When considering whether lay evidence may be 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, 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"). Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet.App. at 435, as to the specific issue in this case, whether the Veteran has an eye disability etiologically related to an event in service, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (providing that lay persons are not competent to diagnose cancer). Indeed, while the Veteran sincerely believes that he has an eye disorder due to service, the medical professional has indicated that there is no present disability associated with the Veteran's reported symptomatology. As such, the preponderance of the evidence of record demonstrates that the Veteran did not incur any injury or disability to either eye as a result of this injury. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for a vision condition must be denied. ORDER Service connection for TBI and residuals thereof is granted. Service connection for a vision disorder is denied. REMAND Finally, the Veteran contends that he is entitled to service connection for a psychiatric disorder (specifically PTSD) in addition to his already service-connected mood disorder. Regrettably, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran is currently service-connected for a mood disorder. While the record does not contain a confirmed diagnosis of PTSD, an anxiety disorder was noted in August 2008. See VA outpatient treatment record dated in August 2008. In light of the varying diagnoses of record, Clemons, and the Veteran's combat status, the Board finds that the Veteran must be scheduled for a VA psychiatric examination before appellate review proceeds. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded an appropriate VA examination to determine whether he suffers from a psychiatric disorder in addition to his service-connected mood disorder that is etiologically related to service. The Veteran's claims file and a copy of this Remand must be made available for review by the examiner. Any indicated tests, studies and evaluations should be conducted. The examiner is asked to identify all psychiatric disorders and address the following: Is it at least as likely as not (i.e., 50 percent or greater probability) that the Veteran has an acquired psychiatric disorder other than service connected mood disorder that is etiologically related to an incident of the Veteran's combat service. The examiner should include in his/her opinion a discussion of the August 2008 VA outpatient treatment record that noted an assessment of anxiety disorder. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner should fully discuss why this is the case. 2. After completion of the above, the claim should be reviewed in light of any new evidence. If the claim is not granted, the Veteran should be furnished an appropriate supplemental statement of the case (SSOC) and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. 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). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs