Citation Nr: 1318704 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 07-07 063 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a left eye disorder, variously diagnosed as keratoconjunctivitis, macular degeneration, cataracts, and Sjogren's syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran had active duty service from April 1943 to January 1946. During the pendency of this appeal, the Veteran passed away. The United States Court of Appeals for Veteran's claims (Court) granted a motion for substitution in March 2011, substituting the surviving spouse as the appellant in this case. See Breedlove v. Shinseki, 24 Vet. App. 7, 13 (2010) (per curium order). Unlike accrued benefits claims that are limited to the evidence of record at the time of the Veteran's death, a substitute claimant would be able to submit additional evidence to be considered by VA that was not of record at the time of the claimant's death. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2008, the Board determined that new and material evidence had been received to reopen the previously denied claim; the claim was then remanded for further development at that time. The case was returned to the Board in May 2009, at which time the Board denied that claim. The Veteran timely appealed the Board's denial to the Court, who vacated the May 2009 denial and returned the case to the Board for further development consistent with a May 2011 memorandum decision. In March 2012, the case was remanded by the Board for further development. The case was returned to the Board, at which time, the Board remanded the claim again in February 2013 for clarification. This matter is once again before the Board. Prior to his death, the Veteran testified at a hearing in April 2008 before a Veterans Law Judge. In November 2011, the appellant was notified that the Veterans Law Judge was no longer employed by the Board and informed of her right to another hearing before a currently-employed Veterans Law Judge. In January 2012, the appellant informed VA that she did not wish to appear for a hearing. 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 A left eye disorder, variously diagnosed as keratoconjunctivitis, macular degeneration, cataracts, and Sjogren's syndrome did not manifest during service, and any left eye disorder is not shown to be causally or etiologically related to service. CONCLUSION OF LAW A left eye disorder, variously diagnosed as keratoconjunctivitis, macular degeneration, cataracts, and Sjogren's syndrome was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 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. Duties to Notify & Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 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 this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, a January 2006 letter was sent to the Veteran prior to the April 2006 rating decision on appeal, i.e., in the preferred sequence. This letter informed him of the type of information and evidence required to reopen the claim and to substantiate the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). In a May 2006 letter he was advised of the downstream disability rating and effective date elements of the service connection claim. See Dingess/Hartman, supra. And, as noted above, the claim was reopened in a June 2008 Board decision. The claim was most recently readjudicated in a May 2013 supplemental statement of the case. Thus, there was no deficiency in notice and a harmless error analysis is not necessary. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board also concludes that VA's duty to assist has been satisfied. The claims file includes the Veteran's service treatment records (STRs) to the extent available. The Board notes that in January 2007, the RO requested clinical records related to a land mine injury between February and March 1944 at 279th Hospital Group, South Wales, England. The National Personal Records Center (NPRC) reported that the Veteran's clinical records were retired to his personnel jacket, which was fire-related. In June 2007 correspondence, VA informed that Veteran that his STRs were retired and would have been included in his personnel jacket, which appeared to have been fire-related. However, VA previously obtained the Veteran's STRs because he filed a claim in 1967, prior to the 1973 fire, which likely destroyed his personnel records. He was also advised that the STRs confirmed his hospitalization in South Wales, France; however, there was no record of a land mine injury. Regardless, the Veteran's reports of the land mine explosion were considered by the VA examiner and the Board. The Board notes that, because his personnel records were presumably destroyed in a fire, there is a heightened obligation to assist the Veteran in the development of his case. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The claims file also contains VA and private treatment records identified by the Veteran and the report of a September 2008 VA examination as well as associated addendum reports dated in October 2008, June 2012, and April 2013. No additional outstanding evidence has been identified. A review of the paper claims file as well as Virtual VA does not reveal any additional documents pertinent to the present appeal. VA has a duty to ensure that its examinations or opinions are adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As the September 2008, October 2008, June 2012, and April 2013 opinions, combined, reflect review of the claims file and assessment of the Veteran's contentions and disabilities, the opinions are adequate. The duty to assist in the gathering of records and a VA opinion has been met and the RO/AMC has substantially completed the February 2013 remand directives by obtaining the requested opinion. Dyment v. West, 13 Vet. App. 141, 146-47 (1999). During the April 2008 hearing, the Veterans Law Judge explained the issue on appeal and asked questions designed to indicate evidence that may have been overlooked. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). No further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant 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). II. Legal Criteria Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a) -benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d 1331 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. §3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). 708 F.3d 1331. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: " The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Id. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). The Board must assess the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). This evaluation generally involves a three-step inquiry. First, the Board must determine whether the evidence is competent. See, e.g. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Third, the Board must assess the probative value and weight of the evidence in light of the entire record. Gonzales, 218 F.3d at 1380-81 . As observed by the Federal Circuit, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). The Board may therefore discount the probative value of lay evidence if it finds such evidence not to be competent. See id.; see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). However, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and his drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent simply because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Importantly, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability. See Davidson, 581 F.3d at 1316. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 469 (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). For example, the Court has held that a lay person is competent to diagnose a disease with "unique and readily identifiable features" such as varicose veins. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Similarly, the Court has found a lay person competent to identify tinnitus and flat feet, which are disorders that can be identified based on lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. See Barr, 21 Vet. App. at 309. For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a more medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Federal Circuit has held that lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Id. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. The competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility and probative value. See Layno, 6 Vet. App. at 469; accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."). The Board discounts the weight of evidence it finds not to be credible. See Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). In determining whether statements submitted by a veteran are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Further, the Federal Circuit has held that while the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). III. Analysis The claimant seeks service connection for a left eye disorder, claimed as due to an in-service landmine blast. The Veteran's service treatment records (STRs) are devoid of any complaints, treatment, or diagnoses related to a left eye disorder or notation of a landmine blast. STRs show treatment for acute catarrhal nasopharyngitis in February 1944 and peritonsillar abscess, right and acute tonsillitis from February to March 1945. The Veteran's vision upon induction was 20/30 in the left eye, both with or without correction. There was no notation of a preexisting left eye disorder upon induction. Upon separation medical examination in January 1946, the Veteran's uncorrected left eye vision was 20/20. There was no mention of a residual disorder of the left eye upon service separation. According to an October 1966 medical certificate, the Veteran had first noticed eye dryness in 1946, with the left eye being worse. He advised that it slowly worsened and he was found to have inactive tear glands. By that time, the Veteran had severe irritation and photophobia affecting his vision. The Veteran was diagnosed as having inactive lacrimation and salivation causing keratoconjunctivitis sicca lente and xerostomia with photophobia, frequent chronic and progressive sore throats with photophobia, and poor vision. There was no opinion given as to the etiology of his eye disorder. In a December 1966 note, the Veteran's private optometrist, Dr. D.L.W., indicated that he had been seeing the Veteran off and on since 1953. He also indicated that a cataract was slowly developing in the Veteran's left eye. The Veteran was noted to have been treated for keratitis and a reduced tear flow in 1959. In 1966, the Veteran's cataracts were noted to be much more opacified with corneal damage. In a December 1966 note, Dr. E.H.M. reported that in the office records showed that the Veteran was treated in March 1953 for an infected throat; in May 1953 for irritation of the left eye and throat, red and inflamed; and in July 1953 for growth on the uvula. An undated pharmaceutical note revealed that the Veteran has been getting Isopto Frin Ophthalmic solution since December 1959. In a letter dated in January 1967, R.D.S., reported that he had worked with the Veteran since 1954 and since this time he had become aware of the Veteran's increasing "trouble" with his eyes. He would wear dark glasses (even indoors and on cloudy days) and used eye drops often. The Veteran told him that he used a prescription because his tear glands did not work properly. In a letter dated in January 1967 from one of the Veteran's former physicians, he indicated that the Veteran was treated for Sjogren's due to dryness of the mucous membranes. The physician opined that it was "not necessarily related to his previous military service although I cannot tell whether or not it was aggravated by the military service." The Veteran's subsequent private treatment records dated from May 2002 to April 2006 from Drs. C.S. and H.L.B., reflect treatment for macular degeneration, cataracts and Sjogren's syndrome. In October 2002 correspondence, Dr. H.L.B. reported that the Veteran was incredibly photophobic and actually has "K sicca." His mouth was extremely dry as well as the front of his eyes. In separate October 2002 correspondence, Dr. H.L.B. indicated that he wanted to "start [him] on a pill that is for keratitis sicca or Sjogren's syndrome which is what he has." In April 2004 correspondence, Dr. H.L.B. reported that the Veteran's cataract surgery was in place, but he had severe dry eye and that plus a dry mouth gave him Sjogren's syndrome. He was placed on Restasis twice a day. In a May 2006 letter from a former employer, the Veteran was noted to have problems with his sight during his employment. The former employer indicated that the Veteran's disability had worsened over the years. No dates were provided regarding this period of employment. The Veteran's wife, in a June 2006 statement, indicated that she recalled the Veteran first having problems with his vision in 1946 shortly after his discharge from service. In another statement from one of the Veteran's former employers, received in June 2006, he recalled that as early as 1951, the Veteran experienced problems with his sight. He stated that by 1952, the Veteran had to be transferred to a position requiring less reading. This former employer also indicated that the Veteran was a man of integrity and honor and had continued to work to support his family, even with his disabilities. The July 2006 private examination report, Dr. C. S. indicated that the Veteran had severe dry eye syndrome and advanced macular degeneration. No opinion was given as to the etiology of his disabilities. In a letter received in December 2006 from the Veteran's county commissioner, he stated that he was writing on behalf of the Veteran as he was a fine citizen and deserved VA benefits. In a letter dated in February 2007, the Veteran's former treating optometrist, Dr. D.L.W. indicated that he had treated the Veteran from 1950 until 1990. He recalled the Veteran having compound astigmatic hyperopia and presbyopia. He remembered the Veteran's greatest difficulty as being an extremely dry external eye, due to reduced tear flow, and especially impacting the cornea. The O.D. stated that the haze in the Veteran's cornea resulted in his reduced vision. In the Veteran's February 2007 Substantive Appeal, he indicated that the trauma to his left eye occurred during advance training while he was still in the U.S. The Veteran suspected that he was switched from a combat medic to a hospital medic because of the injuries he incurred to his eyes and ears. In a June 2007 letter signed by various local officials, they asked that the Veteran be awarded the VA benefits he deserved. In July 2007, the Veteran submitted a statement to VA. He indicated that he was injured during a simulated training exercise while stationed at Camp Barkley , Texas. The Veteran asserted that he first began experiencing eye problems in 1944 and was treated for it twice while stationed in South Wales. In a December 2007 letter, the Veteran's current treating O.D., Dr. C.S. indicated that the Veteran had severe macular degeneration and was legally blind. During the Veteran's April 2008 hearing, he testified that a landmine exploded to his left during a combat medical training exercise. The Veteran recalled being thrown 20 to 30 feet from the explosion and stated that "[i]t got my left ear and the flash got my left eye during that." The Veteran did not report his injury as he was afraid he would be discharged or have to repeat the training. After his January 1946 discharge, the Veteran reported first seeking treatment for his eye disorder in April 1946. He stated that his eyes were in perfect condition before the explosion and had worsened following it. Pursuant to the Board's June 2008 remand, the Veteran underwent a VA examination in September 2008. Noted were the Veteran's reports of in-service trauma resulting in damage to the Veteran's retina, and the examiner indicated that medical records did not support the Veteran's reports. The examiner in his initial examination indicated that the Veteran's military records reflected treatment for dry eyes and early cataracts, but in an addendum the following month (October 2008), indicated that it was in error and he was noted to have first been treated for those conditions following service. The examiner indicated that the Veteran's loss of vision was secondary to macular degeneration and that his vision was normal prior to the macular degeneration. The examiner indicated that the Veteran had a history of cataract extraction and treatment for dry eyes, but there was no treatment recommended for macular degeneration. There was no additional reported eye injury, surgery, or disease found. The examiner indicated that neither dry eyes, nor cataract extraction were visually significant. The Veteran was diagnosed as having legal blindness in each eye most likely secondary to macular degeneration. Further, the examiner indicated that the Veteran's macular degeneration was most likely not related to dry eyes, cataracts, or the reported in-service trauma. In May 2011, the Court concluded that the above VA examiner's opinion was inadequate. Specifically, the Court noted that the examiner failed to provide sufficient rationale in support of his opinions. The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). For example, the Court noted that the examiner concluded that the Veteran's dry eye condition was "not visually significant" without stating any opinion in regard to etiology or service connection. The Court further noted that the examiner only referred to trauma during military service without clarifying whether this specifically referred to a landmine flash. Finally, the Court was of the opinion that the examiner only provided summary conclusions as to etiology without any rationale. Pursuant to the Board's March 2012 remand, the Veteran's claims file was forwarded to the September 2008 VA examiner for an adequate opinion. In the June 2012 addendum, the examiner found that there was no evidence determined by this examiner in full review of C - file to indicate that the Veteran complained or suffered from dry eyes during military service. The examiner opined that dry eyes were less likely as not aggravated or caused by military service and/or reported landmine explosion. The examiner reasoned that he was unaware of literature which supported exposure to a nearby landmine explosion and/or the tour of duty for this Veteran with a chronic dry eye condition. The examiner stated that macular degeneration and cataracts was not caused by or a result of dry eyes, as these conditions were unrelated. Macular degeneration and cataracts were less likely as not aggravated or caused by military service and/or reported proximity to landmine explosion. The examiner reasoned that a review of records indicated that the age of the Veteran when a diagnosis of macular degeneration (which is cause of legal blindness) was made and when cataract extraction with IOL was performed were both consistent with normal age related changes. The examiner reported that both conditions were bilateral which would speak against the Veteran's complaint of left eye trouble secondary to a reported landmine explosion on the Veteran's left side. In February 2013, the Board once again remanded the claim finding it was currently unclear whether the Veteran had Sjogren's syndrome in 2008 at the time of examination, or whether he ever had that disorder. The Board requested another opinion for clarification. In an April 2013 opinion, the same VA examiner noted that he reviewed the claims file in its entirety. The examiner specifically reported that he did not diagnose Sjogren's syndrome in the 2008 VA Compensation and Pension Examination. The examiner stated that he did not locate a diagnosis of Sjogren's syndrome from December 15, 2006 to the present in a review of the medical records. The examiner noted that a review of the Veteran's claims file included an October 2002 letter from Dr. H.L.B to Dr. C.S., which reported that the Veteran was incredibly photophobic, has "k sicca", and had extreme dryness in his mouth as well as the front of his eyes. The examiner found that he was unable resolve the issue whether or not Sjogren's syndrome was misdiagnosed or whether the Veteran had that disorder and such subsequently resolved without resorting to mere speculation. The medical examiner stated that he had no personal knowledge of the competency of Dr. H.L.B; however, it appeared to this examiner that Dr. H.L.B. made his statement based on the Veteran's signs and symptoms of dry eyes and his complaint of a dry mouth. The VA examiner acknowledged that both symptoms were indeed seen in Sjogren's syndrome. Yet, the examiner specifically stated that he saw no objective proof, which was required for a definitive diagnosis of Sjogren's syndrome as indicated by the Sjogren's Syndrome Foundation. The examiner reported that the medical "proof" of Sjogren's syndrome was indeed a strict criterion and noted the criterion in more detail. The examiner indicated that as a result of the strict criterion, the Sjogren's Syndrome Foundation stated that "Physicians usually diagnose SS for clinical purposes on a more individual, medically intuitive and broader basis." The examiner restated that as he found no medical proof of Sjogren's syndrome and had no way of knowing whether or not Dr. H.L.B's reference to Sjogren's syndrome was a correct medical intuition it would be mere speculation to opine whether or not the diagnosis of Sjogren's syndrome was correct or not. The Board finds that the preponderance of the evidence is against entitlement to service connection for Sjogren's syndrome. It appears that the Veteran was treated for Sjogren's syndrome in 1967, 2002, and 2004. However, the April 2013 VA examiner stated that there was no objective proof of Sjogren's syndrome, which was required for a definitive diagnosis as indicated by the Sjogren's syndrome Foundation on the 2008 VA examination and there was no evidence of such a diagnosis since December 15, 2005 to the present in review of the medical records. As there was no evidence of Sjogren's syndrome during the appellate period (i.e., since the Veteran filed his claim for service connection in December 2005), this claim must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). With respect to keratoconjunctivitis, macular degeneration, cataracts, the examiner stated that the dry eye condition was less likely than not incurred in service or caused by an in-service injury event or illness. The examiner reported that based on his review of the claims file, there was no evidence to indicate that the Veteran complained or suffered from dry eyes during military service. The examiner opined that dry eyes were less likely as not aggravated or caused by military service and/or reported landmine explosion. The examiner reasoned that he was unaware of literature which supported that exposure to a nearby landmine explosion and/or the tour of duty for this Veteran with a chronic dry eye condition. The examiner clarified that macular degeneration and cataracts were not caused by or a result of dry eyes, as these conditions were unrelated. Macular degeneration and cataracts were less likely as not aggravated or caused by military service and/or reported proximity to landmine explosion. The examiner reasoned that a review of records indicated that the age of the Veteran when he was diagnosed with macular degeneration (which was the cause of legal blindness) and when cataract extraction with IOL was performed were both consistent with normal age related changes. Additionally, the examiner found that both conditions were bilateral which would speak against the Veteran's complaint of left eye trouble secondary to a reported landmine explosion on the Veteran's left side. The Board acknowledges that the Veteran suffered an injury to his eye during service and finds that he is competent and credible in this regard. The Board also acknowledges the Veteran's complaints of continuing eye symptoms since service. However, the June 2012 VA examiner, after considering the Veteran's lay statements and the medical evidence, determined that the Veteran's dry eye condition , cataracts, and macular degeneration were not related to service. The June 2012 VA addendum to the September 2008 Compensation and Pension examination is highly probative because the opinion is based on review of the claims folder, including the Veteran's STRs, and the opinion thoroughly discusses in-service and post-service medical and lay evidence as well as the alleged in-service landmine explosion. The VA examiner offered a detailed explanation of the rationale for the opinion that incorporates both the facts of the Veteran's case and the pertinent medical principles. The Board finds this opinion to be the most probative evidence of record. The Veteran's lay statements are outweighed by the medical evidence of record. The Veteran's assertion that his left eye disorder is related to service has been investigated by competent medical examination and found not supportable. Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007). Therefore, the Board finds that the preponderance of the evidence is against entitlement to service connection for a left eye disorder, variously diagnosed as keratoconjunctivitis, macular degeneration, cataracts, and Sjogren's syndrome. The benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Therefore, the claim must be denied. ORDER Entitlement to service connection for a left eye disorder, variously diagnosed as keratoconjunctivitis, macular degeneration, cataracts, and Sjogren's syndrome, is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs