Citation Nr: 1318997 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 95-23 741 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for arthritis of multiple joints to include as due to Agent Orange exposure and as secondary to service connected skin disorder. 2. Entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for arthritis of multiple joints as due to VA treatment for a skin disorder. 3. Entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for a vision disorder as due to VA treatment for a skin disorder. 4. Entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for a kidney disorder, including hematuria, as due to VA treatment for a skin disorder. [The issues of entitlement to an initial evaluation in excess of 10 percent for osteoporosis of the cervical spine, entitlement to an initial evaluation in excess of 10 percent for osteoporosis of low back, entitlement to an initial evaluation in excess of 10 percent for osteoporosis of left knee, and entitlement to an initial evaluation in excess of 10 percent for osteoporosis of right knee are the subject of a separate decision.] REPRESENTATION Veteran represented by: Daniel G. Krasnagor, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran had active service from June 1966 to April 1970. The case has a complex history. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by which the RO collectively denied service connection (including as due to Agent Orange exposure), secondary service connection, and compensation under 38 U.S.C.A. § 1151 (based on VA medical treatment for a skin disorder), for, in pertinent part, the following conditions: arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria). Board hearings were held in May 1997 and October 2001; the Board remanded the case in September 1997, December 1998, August 2005, July 2006, February 2008, July 2011, and October 2012, to address other concerns of the Veteran's attorney at different stages of the appeal, notwithstanding the fact that the Veteran was in receipt of a 100% evaluation. The Veteran testified at a hearing before a Veterans Law Judge (VLJ) other than the undersigned in October 2001. However, since that hearing, the VLJ has left employment with the Board. By letter dated in March 2005, the Veteran was offered an opportunity to have another Board hearing before a different VLJ. See 38 U.S.C.A. § 7107(c); 38 C.F.R. § 20.707 (2012) (the Board Judge who conducts the hearing will participate in making the final determination of the claim). The Board did not receive any response to this request and proceeded to evaluate the appeal. In an August 2002 decision, the Board denied service connection (including as due to Agent Orange exposure), or compensation under 38 U.S.C.A. § 1151 (based on VA medical treatment for a skin disorder), for, in pertinent part, arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria). The Veteran then appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In July 2003, the Veteran and the VA Secretary (the Parties) filed a joint motion requesting the Court to vacate and remand the Board decision. A July 2003 Court order granted the motion and remanded the matter to the Board for compliance with the instructions in the joint motion. It is important to note that since this time, the Veteran's attorney has requested several extensions in order to submit additional argument, delaying the adjudication of this case, beyond providing different reasons for remanding the case at different times in the appeal, also delaying the case further. To ensure compliance with the terms of the joint motion, in August 2005, the Board remanded the case for the RO to provide the Veteran with notice and assistance under Veterans Claims Assistance Act of 2000 (VCAA). The RO complied with the above request by sending a VCAA letter to the Veteran in December 2005. The RO then issued a supplemental statement of the case in March 2006. In July 2006, the Board, in pertinent part, addressed entitlement to benefits under 38 U.S.C.A. § 1151 and entitlement to service connection for arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria), to include as due to Agent Orange exposure, and to include as secondary to his service-connected skin disorder. First, the Board remanded the claim for entitlement to benefits under 38 U.S.C.A. § 1151 so that the RO could provide proper VCAA notice of the regulations associated with 38 U.S.C.A. § 1151 claims filed prior to October 1, 1997. Review of the actions performed by the RO reveals that the mandate of that remand has been substantially fulfilled. Stegall v. West, 11 Vet. App. 268 (1998). A supplemental statement of the case was provided in June 2007, which continued to deny compensation under 38 U.S.C.A. § 1151. The Veteran indicated that he wanted to proceed with the appeal. Second, the Board denied, in pertinent part, service connection for the following conditions: arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria), to include as due to Agent Orange exposure, and to include as secondary to his service-connected skin disorder. In August 2007, the Court granted another joint motion of the parties, vacated the Board's July 2006 decision, and remanded the matter for compliance with the instructions in the joint motion. To ensure compliance with the instructions in the joint motion, in February 2008, the Board remanded the matter to obtain updated VA treatment records, to obtain a copy of the VA Agent Orange examination conducted in August 1998, and to inquire about and obtain any other outstanding private treatment records. In October 2009, the Board issued a decision that granted service connection for osteoporosis. The Board denied entitlement to service connection for arthritis of multiple joints, to include as due to Agent Orange exposure and as secondary to a service-connected skin disorder. The Board also denied entitlement to benefits under 38 U.S.C.A. § 1151 for, in pertinent part, arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria), as a result of VA treatment for a skin disorder. In April 2011, the Board vacated the October 2009 decision as to all matters decided unfavorably to the Veteran, in light of the Veteran's attorney's request to submit additional written argument prior to the Board decision. In July 2011, the Board denied entitlement to service connection for heart disease, denied compensation for heart disease under 38 U.S.C.A. § 1151, and remanded the remaining issues for additional development. In October 2012, the Board denied entitlement to service connection for hypertension, denied compensation for hypertension and fever blisters under 38 U.S.C.A. § 1151, and remanded the remaining issues for additional development. As noted above, the issues of entitlement to increased ratings for service connected osteoporosis of the cervical spine, low back, left knee, and right knee are addressed in a separate Board decision. In light of the fact that the veteran has been in receipt of a 100 percent evaluation since 1996, he may wish to reconsider filing additional claims. Notwithstanding, in October 2012, the Board asked the RO to determine whether the Veteran raised certain additional claims in an August 2010 correspondence, to avoid additional litigation in this matter (and in light of the fact that the Veteran's statements are not always clear). However, in light of the fact that the Veteran is represented by an attorney with experience in Veterans Law, the Board expects no further miscommunications or gratuitous delays. FINDINGS OF FACT 1. The Veteran's arthritis of the joints was not incurred in or caused by active service, including exposure to Agent Orange, and is not the proximate result of a service-connected disability. 2. The Veteran was not treated for arthritis of the joints within one year of separation from service. 3. Arthritis of multiple joints was not caused or worsened by VA medical treatment for the Veteran's service-connected skin disorder, and there is no additional disability due to VA medical treatment. 4. The Veteran's loss of vision was not caused or worsened by VA medical treatment for the Veteran's service-connected skin disorder, and there is no additional disability due to VA medical treatment. 7. The Veteran has microscopic hematuria unrelated to a kidney disorder. 8. The Veteran's claimed kidney disorder, to include hematuria, was not caused or worsened by VA medical treatment for the Veteran's service-connected skin disorder, and there is no additional disability due to VA medical treatment. CONCLUSIONS OF LAW 1. Arthritis of multiple joints was not incurred in service, was not proximately due to or aggravated by a service-connected disability, and service connection for arthritis of multiple joints may not be presumed based on the one year presumption for a chronic disease or based upon herbicide exposure. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for compensation under 38 U.S.C.A. § 1151 for arthritis of multiple joints, loss of vision, and a kidney disorder, all claimed as due to VA medical treatment, have not been met. 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. § 3.358 (prior to October 1, 1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The service treatment records do not refer to complaints of or treatment for arthritis of any joint, or for loss of vision. At the time of the June 1966 entrance examination report, the Veteran was noted to have 20/20 vision in both eyes without correction. There were also notations that the Veteran's eyes, ophthalmoscopic evaluation, pupils, ocular motility, genitourinary system, skin, and the musculoskeletal system were normal. A March 1968 treatment entry noted that the Veteran had complaints including burning on urination. Another March 1968 entry indicated that the Veteran was discharged from the hospital after a urinary tract infection. A March 1968 clinical record cover sheet related a diagnosis of pyelonephritis, acute. Additionally, a May 1969 treatment entry noted that the Veteran had a 2 by 3-cm cystic tenderness on the right cheek as well as a 1 by 1-cm mass on the forehead. The impression referred to an abscess. A later May 1969 entry also noted a cystic mass on the cheek. A May 1969 consultation report indicated that the Veteran had cystic acne vulgaris of the face. The February 1970 separation examination report noted that the Veteran had acne that was treated and controlled by medication. It was also reported that the Veteran had pyelonephritis in March 1968 and that he was hospitalized for one week and made a good recovery. The examination report further indicated that the Veteran's vision was 20/15 in both eyes without correction. There were notations that the Veteran's eyes, ophthalmoscopic evaluation, pupils, ocular motility, genitourinary system, skin, and musculoskeletal system were normal. The Veteran underwent a VA general medical examination in December 1971. As to the Veteran's eyes, it was reported that his extraocular muscles were intact, and there was no retinopathy. The examiner reported that the Veteran's vision was 20/20, uncorrected. As to the Veteran's genitourinary system, it was noted that there was normal escutcheon and that the testicles were free of disease. The examiner noted that the Veteran's joints showed a good mobility and a normal range of motion. The diagnosis was kidney disease, not found. The Veteran also underwent a dermatological examination for VA purposes in December 1971. The examiner noted that the Veteran had severe cystic and conglobate acne occurring over the malar areas of the face. It was noted that there was a less pronounced eruption over the buttocks, anterior chest, and in the groin area. The diagnosis was cystic acne. The examiner commented that he did not think that the development of cystic acne should be attributed to the Veteran's tour in Vietnam. The examiner also remarked that treatment was difficult and involved various antibiotics as well as local injections of cortisone and other types of topical therapy. In January 1972, the RO granted service connection for a skin disability, and a 10 percent rating was assigned. A May 1972 VA hospital summary noted that the Veteran was seen with a history of acne vulgaris since 1969. The Veteran was treated with medications including systemic Prednisone of 20 mgs daily. The diagnoses were acne vulgaris and hidradenitis suppurative. In May 1972, the RO re-characterized the Veteran's service-connected skin disability as acne vulgaris and increased the rating from 10 percent to 30 percent. The Veteran underwent a VA general medical examination in July 1972. At that time, the examiner noted that the Veteran's eye examination was negative. It was noted that the Veteran had 20/20 vision in both eyes. As to the Veteran's genitourinary system, the examiner noted that the Veteran's had normal external genitalia. The examiner further reported, as to the Veteran's musculoskeletal system, that there was no evidence of serious diseases or injuries and that the only scars were from acne. The examiner stated that orthopedically, the examination was within normal limits. A July 1972 dermatological examination report for VA purposes related diagnoses of severe scarring acne vulgaris of the face and hidradenitis, suppurative, both axilla. VA treatment records dated from September 1973 to November 1973 reflect that the Veteran was treated for skin disabilities. A September 1973 VA hospital summary noted that the Veteran was admitted for an exacerbation of his severe acne problem with many areas affected. It was noted that the Veteran was given medications including Prednisone with 20 mgs daily. The diagnoses were acne conglobata and hidrosadenitis, suppurative by history. An October 1973 treatment entry noted that the Veteran was seen secondary to a fever and a rash. The assessment was that the Veteran responded to Prednisone with decreased fever and improvement of his skin eruption. An October 1973 VA hospital summary noted that the Veteran was found to have an exacerbation of his acne problem with an increase in the number and severity of the cystic lesions in the intercommunicating channels. The report indicated that the Veteran's previous medication of Clindamycin was discontinued and that he was begun on Dapsone, 50 mgs, and a low dose of oral Prednisone which was tapered throughout the remainder of his hospitalization. The Veteran also had his lesions injected with Triamcinolone on one occasion. The report noted that during the hospitalization, the Veteran was found to have improved and that the improvement persisted after the oral Prednisone was discontinued. It was reported that at the time of discharge, the Veteran was somewhat symptomatic and complained of dizziness on standing rapidly with some gastrointestinal discomfort. The report also noted that there was a drop in the Veteran's hemoglobin and hematocrit from his admission probably resulting from the Dapsone treatment. It was reported that it was expected that the Veteran would accommodate such treatment and that it would not be serious medical problem. The Veteran was given Dapsone 100 mgs tablets to be taken twice daily. The diagnoses included acne conglobata and hidrosadenitis, suppurative. A later October 1973 treatment entry noted an assessment of anemia thought to be secondary to Sulfone treatment. It was noted that Sulfone treatment characteristically produced a hemolytic anemia which could be quite severe. A November 1973 VA hospital summary noted that the Veteran presented with chills and fever for approximately four to five days prior to admission. The report noted that the Veteran had been treated with numerous medications in the past, which included antibiotics, Prednisone, intralesional Triamcinolone, and Dapsone. It was reported that it was believed that the Veteran had a hemolytic process, probably secondary to the Dapsone therapy. The diagnoses were acne conglobata and hemolytic anemia secondary to Dapsone therapy. Private treatment records dated from March 1975 to April 1976 show that the Veteran was treated for several disabilities. The Veteran underwent a VA dermatological examination in November 1976. It was noted that he had actually developed septicemia and very severe illness from his acne problem in the past and that he had developed a life threatening hemolytic anemia while under treatment for his acne problem. The impression was acne vulgaris. VA treatment records dated from September 1979 to December 1993 show that the Veteran was treated for multiple disabilities including cystic acne and acne conglobata as well as polyarthritis, nephritis, and hematuria. A September 1979 entry related an assessment of polymyalgia of an unknown etiology, possibly secondary to medication. A June 1988 treatment entry noted that the Veteran complained of intermittent dysuria. The diagnosis was prostatitis. An August 1988 entry noted that the Veteran was seen for follow-up of acne conglobata and that he had two previous rounds of Accutane. It was noted that the had two active lesions on the upper lip. The assessment was acne conglobata. A September 1988 entry reported that the Veteran complained of recurrent sacroiliac joint pain. A November 1988 entry noted that the Veteran complained of swelling in the upper chest for the previous week which was painful. The diagnosis was costochondritis with questionable sternoclavicular joint swelling. A March 1989 treatment entry noted that the Veteran complained of a rash on the penis. The diagnosis was probable herpes simplex II. Another March 1989 entry noted that the Veteran had a history of polyarthritis of unknown etiology. At that time, the Veteran described excruciating pain which varied in the knees, hips, and sternoclavicular area as well as pleuritic chest pain. It was also noted that the Veteran had a positive history for urethritis. The impression was polyarthritis of an unknown etiology with the need to rule out Reito's syndrome and rheumatoid arthritis. An April 1989 entry noted that the Veteran was seen for follow-up of his polyarthritis, especially of the low back and hips. The impression was polyarthritis, sero-negative. The Veteran had an examination in conjunction with his participation in the Agent Orange Registry. The examination, dated in August 1988, indicates that the Veteran's laboratory tests were essentially within normal limits. He was diagnosed with acne, back pain, and joint pain. A May 1989 treatment entry noted that the Veteran had polyarthritis and that he complained of right flank pain, left shoulder pain, and sternoclavicular pain. The assessment was polyarthritis, seronegative. Another May 1989 entry noted that the Veteran complained of pain in the right kidney area. He also reported some burning with urination as well as some blood about twelve weeks earlier. An additional May 1989 entry noted that an intravenous pyelogram showed a lower pole calyx with contrast collection adjacent on the right which could represent a possible focal pyelonephritis. A further May 1989 entry related a diagnosis of hematuria. A July 1989 treatment entry noted that the Veteran had an episode of hematuria that morning. There was a notation that his urine was 2+ for occult blood. An August 1989 entry noted that there was no hematuria at the present time. It was also reported that the Veteran had a history of a resolved urinary infection and that an intravenous pyelogram had shown focal polynephritis. A September 1989 entry also noted that an intravenous pyelogram showed focal pyelonephritis. An October 1989 entry noted that the Veteran had a group of blisters on his penis. The provisional diagnosis was questionable herpetic lesions. A July 1990 entry indicated that the Veteran was seen for a follow-up of wrist and bilateral knee pain. The assessment was polyarthritis. A November 1992 lay statement from E.L.J. noted that the Veteran began to complain of back and leg problems about five years earlier. It was reported that the Veteran developed a limp and that he required crutches to get around. A December 1992 lay statement from M.E.P. noted that the Veteran's physical condition had deteriorated tremendously and that he presently used a cane. An undated lay statement from L.D.J-S also referred to the Veteran's physical troubles. The Veteran underwent a VA general medical examination in January 1994; however, it does not appear that the examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he had increased pain in the neck, back and, knees. The Veteran also reported that his neck, wrist, and back would swell. It was noted that the Veteran denied any venereal disease, penile lesions, urological manipulation, or urological evaluation by a urologist. The examiner indicated that the Veteran had full range of motion of his neck and reported some limitation of motion of the lumbar spine. The examiner also reported that, as to the Veteran's genitourinary system, there were no penile lesions or secretions. The diagnoses were osteoarthritis of the neck, back, and knees with no apparent dystrophy in a new recurrent nature; history of bleeding from the rectum and the penis, with the examiner noting that he had no medical records to substantiate such claims; and osteoarthritis of the jaw. VA treatment records dated from September 1994 to October 1994 refer to continued treatment. A September 1994 entry noted that the Veteran complained of frequent urination for years. The assessment was nocturia. An October 1994 entry related an assessment of osteoarthritis. The Veteran submitted medical treatises on multiple medications in March 1995. VA treatment records dated from August 1995 to November 1995 reflect that the Veteran was treated for several disabilities including chloracne. The Veteran underwent a VA general medical examination in March 1996. The examiner reviewed the claims file in conjunction with the examination. It was noted that in approximately 1972, the Veteran was placed on Dapsone and Prednisone for generalized acne and that sometime thereafter he had developed hematuria and rectal bleeding. The Veteran also reported that he had developed hemolytic anemia. The Veteran stated that he had not been on Prednisone since around 1980. The Veteran also reported that he had high urinary frequency and complained of some pain in his neck, right shoulder, and both knees and indicated that he had been told that he had degenerative arthritis that he felt was caused by Prednisone. The examiner indicated that the Veteran's genitourinary examination was that of a normal adult male. As to the Veteran's musculoskeletal system, it was noted that the curvature of the cervical spine was normal and that the knees revealed a little crepitus on exertion. Range of motion of the cervical spine, shoulder, and knees was reported. The diagnoses were, in pertinent part, degenerative arthritis of the cervical spine; degenerative arthritis of the right acromioclavicular joint; genitourinary disease, not found; and renal disease, not found. The examiner commented that he did not detect residuals of Dapsone or Prednisone therapy and that the Veteran's degenerative arthritis of the cervical spine and right acromioclavicular joint were not related to Dapsone treatment. A rationale for the examiner's opinion regarding Dapsone treatment and the Veteran's disabilities was not provided. The Veteran also underwent a VA dermatological examination in March 1996. He reported that he had chloracne which was first diagnosed and treated in Vietnam. The Veteran also stated that he developed complications as the result of medication used to treat his chloracne. He indicated that he was treated with Prednisone and Dapsone. The Veteran noted, specifically, that he was treated with Dapsone in 1972 and that he developed a severe life-threatening hemolytic anemia as a result of the Dapsone. The assessment was severe scarring, extensive chronic acne and history of possible complications as a result of the above treatment. The examiner commented that the Veteran had severe disfigurement as a result of the acne and that the appearance could be consistent with chloracne. The Veteran underwent a VA ophthalmologic examination in April 1996. The examiner reported that the Veteran's vision in both eyes was 20/200, uncorrected. The Veteran's corrected vision was 20/25 in both eyes. The diagnoses included corneal scar, possibly leading edge of pterygium and macular mottling, cause unknown, not influencing vision. At a March 1997 Board hearing, the Veteran testified that he was treated with Sulfone and Dapsone in 1972 or 1973 that he stated were medications used for leprosy. He indicated that such medication caused him to become hemolytic and anemic. The Veteran also reported that he was put on Prednisone. He indicated that shortly thereafter, he began having problems with joint soreness. The Veteran stated that he was on Prednisone from 1972 to 1987 or 1988. He related that when he was on Prednisone, he was having a tightness in his chest and that his neck and joints were sore. It was also reported that the Veteran took Accutane, which caused other symptoms. The Veteran further indicated that he felt some of his joint problems may have been a result of his chloracne. He indicated that he had blurred vision and that he had a "spot" on the eye. In May 1997, the Veteran submitted medical treatises on chloracne as well as a transcript from the Oprah Winfrey show. The Veteran underwent a VA orthopedic examination in March 1998. It was noted that the Veteran's claims file and clinical files were present and that all files were reviewed as completely as possible. The Veteran reported that he received steroid treatments from 1972 to 1988 and that he had blood in his urine. He indicated that he had excruciating pain in his neck with tightness and stiffness. The Veteran also stated that he had pain in his low back and knees. The examiner evaluated the Veteran's cervical spine, shoulders, elbows, wrists, hands, lumbar spine, knees, ankles, and muscles of the upper and lower extremities. The examiner indicated that the overall impression of the Veteran's skeletal system suggested that he had coarse trabeculae and thin cortises to his bones. It was reported that the Veteran had some impairment of his bone formation in the past from which he had not recovered. The diagnoses were arthrosis, right sacroiliac joint; degenerative arthritis of the cervical spine; bone spur of the great toe phalanx; chondromalacia of the patella, grade I, right knee; and generalized osteoporosis. The examiner commented that in his opinion, it was quite probable that the Veteran's osteoporotic changes were secondary to medication given in the past. The examiner remarked that with the Veteran's history of prolonged cortisone administration, he would suspect that such was a primary agent of inception. The examiner further stated that the examination did not demonstrate muscular weakness and that the Veteran did have some osteoarthritic changes as noted. The examiner indicated that it was his opinion that the osteoarthritic changes were due to microtrauma experienced by an adult over a period of 50 years and that the degenerative changes or osteoarthritic changes were not secondary to a form of medication. The examiner noted that if such changes were secondary to a form of medication, there would have been a consistent symmetrical pattern throughout the Veteran's entire joint system. The Veteran also underwent a VA ophthalmological examination in March 1998. The examiner noted that the Veteran had 20/400 vision in both eyes without correction. His vision was 20/25, corrected. It was noted that there was a pterygium on the left eye. The diagnosis was myopia. The Veteran underwent a VA dermatological examination in April 1998, and the examiner reviewed the claims file. The Veteran indicated that he had suffered lesions of the scalp and in the groin area when he was diagnosed has having hidradenitis suppurativa. It was noted that the Veteran still had what was called a follicular occlusion triad where he would experience hidradenitis, dissecting cellulitis of the scalp and severe pustular acne. As to an impression, the examiner noted that the Veteran had severe acne that he suspected was tropical acne. It was noted that he did not see evidence of comedone formation although such had been said to be due to Agent Orange in some of the clinic notes. The examiner stated that the evidence of chloracne was not striking presently, but that he suspected that the Veteran had more evidence for tropical acne. The examiner indicated that he did not know whether or not there was dioxin involvement in such acne, but that the evidence of tropical acne was probably better than the evidence of Agent Orange. It was also noted that the Veteran had a history of what sounded like follicular occlusion triad as well as a history of having had herpes simplex. The examiner remarked that the Veteran had severe scarring from what was probably a tropical acne and that such was almost always limited to people who had lived in the tropics and that the only people he had seen with tropical acne were in the military. The Veteran underwent a VA examination in May 1998. It was noted by the examiner that he had thoroughly reviewed the Veteran's voluminous medical files. It was reported that on one occasion in the Veteran's records, it was noted that the Veteran had some musculoskeletal chest pain after a fishing trip. The Veteran reported that he was given medication in the early 1970s for rather severe acne and that such medications included Dapsone, Sulfone, and Prednisone. The examiner noted that the Veteran had developed a hemolytic anemia secondary to Dapsone. The examiner indicated that such had been completely reversed and that the Veteran had normal blood counts in recent times. It was noted that the Veteran stated that he periodically noted blood in his urine, but that a diagnosis of kidney disease had never been established. The examiner indicated that the Veteran had always had normal blood area nitrogens and serum creatinine levels. It was reported that the Veteran complained of some urinary frequency and indicated that he had nocturia three or four times a night. The examiner reported that the Veteran's penis and testicles were normal and that there was a normal male escutcheon. The impression included hemolytic anemia in the early 1970s, documented, as a result of Dapsone therapy, clinically compensated; and recurrent hematuria secondary to sickle cell trait, unrelated to dapsone therapy. The examiner commented that it was well known that a sickle cell trait at times manifested itself as hematuria. The examiner stated that the Veteran did not have documented kidney disease and that people with sickle cell traits would occasionally develop micro infarcts in the vasculature of the kidney and have gross hematuria. The examiner noted that the Veteran did not have compromised renal function at any time. The examiner stated that the Veteran's hemolytic anemia was related to the Dapsone, but that the condition was currently corrected. A VA examiner provided a comprehensive report in May 1998. The examiner reviewed the claims file and indicated that the Veteran had extensive comedo (blackhead) formation which could be associated with Agent Orange exposure. However, the examiner indicated that the Veteran's extensive cystic and pustular acne was perhaps more compatible with tropical acne. It was also noted that the Veteran had follicular occlusion triad and that such had not been described as a component of chloracne. As to whether the Veteran had symptoms or findings which were due to medications for his service-connected skin condition, the examiner stated that osteoarthritis could be associated with the underlying condition more than the treatment for it and that sometimes arthralgias could be associated with the extensive pustular disease that the Veteran had suffered. He stated that anemia could be the result of Dapsone therapy, particularly if the person is deficient in glucose-6 phosphate dehydrogenase. As to loss of vision, the examiner indicated that he was not familiar with any reason for loss of vision in the treatments that he had found on reviewing the Veteran's chart from the early 1970s to 1997. As to kidney problems, the examiner stated that he knew of no reasons why someone would have kidney problems except that the Veteran did have extensive hemolysis at on time. The examiner noted that he knew of no kidney problem that the Veteran developed from that. In an addendum received in August 1998 to the May 1998 comprehensive report, the examiner stated that Agent Orange may have been a minor factor, at best, to the Veteran's claimed secondary disabilities. He further stated that the treatment given the Veteran was within what he thought the medical community considered proper when it was done. He said that the Veteran's military service is the major contributing cause to his disabilities is highly probable. In August 1998, the RO recharacterized the Veteran's service-connected skin disability as acne vulgaris (chloracne) and increased the rating from 30 percent to 50 percent. Service connection was granted and denied for multiple other disabilities. Lay statements from several individuals dated in August 1998 and September 1998 referred to the Veteran's multiple physical problems. In an undated statement, C.S., a medical lab technologist, indicated that medical research had shown that there were drugs which altered the lifespan of cells responsible for the repair work of bone cavities weakened by steroids and osteoporosis. She stated that steroidal induced osteoporosis was a byproduct of medical advances and that one such steroid which was linked to damage caused by long-term use was Prednisone. She stated that she had witnessed such a bone crippling effect in the Veteran. It was also stated that the Veteran had suffered from adverse reactions due to Prednisone such as muscle weakness, an increase in pain, and restriction of joint motion. A September 1998 private medical report from C.N., M.D. indicated that the Veteran was seen for jaw discomfort. Dr. C.N. indicated that if the pathology report showed osteopenia and osteoarthritis, then it was highly likely that the Veteran's temporomandibular joint problems were secondary to prolonged steroid therapy associated with the Veteran's skin disorder. The Veteran underwent a VA orthopedic examination in January 1999. The impression was by history, arthrosis, right sacroiliac joint; degenerative arthritis, cervical spine, C4- C5 and C5-C6; and chondromalacia of the patellae, early grade, bilateral. The examiner commented that the Veteran did not have disseminated joint processes as evidenced by the lack of changes in his hands and any advanced destructive change within the knees considering the onset of the Veteran's difficulties which according to him date back 27 years. The examiner noted that the changes that were described in the above areas in his opinion represented the effects of microtrauma occurring over a period of time and could not be associated with a single incident of trauma. The examiner remarked that having classified the type of arthritic change and the degree or areas of location based on this and current studies, the question as to whether the changes are related to exposure to Agent Orange or medication taken for the Veteran's service-connected skin disorder could best be answered by an additional opinion from a pharmacologist and/or clinician with experience in diagnosing and treating the effects of chemicals related to Agent Orange. The Veteran underwent a VA genitourinary examination in February 1999. It was noted that the his claims file had been reviewed. The Veteran reported that he had a history of gross hematuria for approximately 20 years. He indicated that he had undergone a cystoscopy in the past which was negative. The examiner noted that the Veteran had a history of urinary tract infections in the past, but that he had none recently. The examiner reported that an intervenous pyelogram done in 1989 showed some changes consistent with pyelonephritis in the past. It was noted that the Veteran reported that he had some bladder outlet obstructive signs and symptoms and that his urinalyses from 1989 to June 1998 had all been normal and showed no evidence of hematuria. The Veteran indicated that he felt his hematuria was secondary to the initiation of Prednisone and Dapsone therapy. As to an impression, the examiner indicated a history of gross hematuria with negative cystoscopies in the past. The examiner noted that the Veteran's urinalyses had all been normal and that he never had a definite urine culture that had been positive. The examiner remarked that he knew of no definitive association between Dapsone therapy and hematuria. In an April 1999 addendum, a VA examiner reported that he had reviewed the January 1999 VA orthopedic examination report and that no other records were available for review. The examiner indicated that the Veteran had a history of arthrosis of the right sacroiliac joint, degenerative arthritis of the cervical spine at C4-C5 and C5-C6, and chondromalacia of the patellae, early grade, bilateral. The examiner commented that there was no known relationship as to exposure to Agent Orange which would cause those particular medical problems and in his opinion, they were unrelated. In an April 1999 addendum to the February 1999 VA genitourinary examination, the examiner stated that he knew of no association or connection with Dapsone therapy and gross hematuria. The examiner also stated that in his opinion and estimation, the Veteran had failed to document any significant hematuria. The examiner commented that he was unable to give a diagnosis for the Veteran's gross hematuria because, he was not convinced that hematuria existed. He stated that they had attempted to perform diagnostic tests on the Veteran to see if there might be any sort of relation, but the Veteran had failed to report for the tests. In an undated addendum to the January 1999 VA examination for TMJ, not discussed herein, the VA examiner was asked to opine as to whether massive doses of steroids have or have not caused the TMJ problems. The examiner stated that the question could be answered by the fact that in other joints of the body, large doses of steroids cause avascular necrosis in the hips, knees, and shoulders and that it could not be proven or disproven that the similar mechanism could have occurred in the Veteran's TMJ. He stated that in light of the fact that VA did surgery to the Veteran's joints, it is assumed that the joint problems were caused by the massive doses of steroids. He concluded stating that it cannot be said that the steroids did not cause the Veteran's joint problems. The Veteran submitted additional medical treatises in August 1999 including information on fibromyalgia. A June 2000 statement from Dr. N.M.S-L, M.D., noted that she had reviewed inpatient and outpatient medical records from various VA hospitals. Dr. S-L noted that the Veteran had been diagnosed as having acne globata which was later termed chloracne. She indicated that it was apparent that initially Dapsone was administered for treatment of the Veteran's severe acne and that later Prednisone was given to ameliorate some of the complications experienced as a result of the use of Dapsone and in an attempt to resolve the skin condition. Dr. S-L stated there was no clear indication for the administration of Dapsone, which was administered for a prolonged period for acne. She noted that the Veteran had depression recurrent gastritis with evidence of rectal and penile bleeding, chronic fatigue syndrome, chronic anemia, osteoarthritis, and a progressive TMJ disorder as well as other conditions. She indicated that a review of medical literature listed all such entities as side effects/complications from use of Dapsone and Prednisone and especially for such a prolonged period. Dr. S-L indicated that in 1973, there was no indication for the use of Prednisone for acne and that in 1972 to 1973, the only indication from the manufacturer for the use of Dapsone was in the treatment of leprosy. She commented that, therefore, it was her professional opinion that the treatment rendered the Veteran from the VA hospital must be considered as experimentation and nothing less, and, that therefore it was malpractice. The Veteran also submitted newspaper articles in support of his claim in October 2001. At an October 2001 Board hearing, the Veteran testified that he had lower back pain. The Veteran further reported that he had blurred vision and that his night vision was extremely poor. VA outpatient treatment records, dated 2007 and 2008, show continued treatment for skin problems. An outpatient treatment record dated April 2008 shows that the Veteran was treated for his acne. The record noted the history of Accutane use, which resulted in side effects such as lip swelling and severe peeling of the scalp. The doctor found contact dermatitis and pruritus. He was diagnosed with acne/pyoderma and seborrheic keratoses. In April 2009, the Board sent the Veteran's claims file to a medical specialist for an opinion regarding the Veteran's claims. In May 2009, the examiner reviewed the claims file and provided a summarized history of the Veteran's medical treatment. Based on a review of the claims file, the examiner stated that there was no clear notation either in the service treatment records or claims file progress notes that the Veteran was treated with prednisone in high doses for prolonged periods of time even though different providers had mentioned it at various times. The examiner was not convinced about the duration and strength of prednisone used based on the record. She found no indication of loss of vision. The Veteran's corrected visual acuity was normal. The examiner stated that microscopic hematuria was trace and not significant and that kidney function was normal. The examiner stated that the Veteran had arthritis of the joints, but that the condition was not related to the antibiotics used in the service or after service, and to the examiner's knowledge, antibiotics do not cause degenerative arthritis. Further, steroids did not cause degenerative arthritis. Finally, to the examiner's knowledge, arthritis of multiple joints was not related to Agent Orange exposure. In the opinion, the examiner stated that the Veteran's arthritis of multiple joints was less likely as not secondary to the Agent Orange exposure. She also stated that the Veteran's claimed arthritis of multiple joints, loss of vision, and kidney disorder were all less likely as not a result of medication use to treat his service connected skin disorder. An addendum was sought by the Board in August 2009 to clarify the May 2009 opinion. The examiner reviewed the claims file and her May 2009 report and opined that based upon the medical literature and evidence of steroid use in the claims file, that osteoporosis is at least as likely as not related to steroid use in service. However, the examiner stated that based upon her knowledge and expertise, that the diagnosis of osteoarthritis, polyarthritis, was less likely as not related to the use of steroids in service as she could not find any evidence to substantiate the relationship between arthritis and the use of steroids in the literature. She further stated that it was her opinion that the diagnosis of osteoarthritis, polyarthritis, and osteoporosis were less likely than not related to the Agent Orange exposure. This opinion was based, in part, on the Veterans and Agent Orange Update, 2006, Institute of Medicine of the National Academies. A June 2010 VA progress note indicated a diagnosis of a urinary tract infection with hematuria. The hematuria was expected to resolve gradually. Antibiotics were prescribed. In November 2011, Dr. L-S wrote that a review of the record revealed that Accutane was prescribed for the Veteran's skin condition at various times "from 1998 through 1990." According to Dr. L-S, Accutane had significant side effects that could limit its utility in some patients and that the Veteran was such a patient. Dr. L-S asserted that some of the medical literature linked the use of Accutane to pruritus and facial erythema. It was, therefore, reasonable to conclude that the Veteran's use of Accutane caused his scalp pruritus and facial erythema. On February 2013 VA shoulder and arm examination, the examiner diagnosed bilateral shoulder degenerative changes. The examiner opined that the degenerative changes were due to repeated microtrauma resulting from the normal aging process. It was not due to the Veteran's skin condition or treatment for the skin condition and was no due to negligent treatment on the part of VA. Furthermore, it was unrelated to service. On February 2013 VA neck examination, the examiner diagnosed degenerative disc disease of the cervical spine. The examiner noted that degenerative disc disease of the neck was initially diagnosed in 1999 and that the Veteran has had chronic neck pain since. The examiner opined that the degenerative disc disease of the cervical spine was due to repeated microtrauma resulting from the normal aging process. It was not related to service, it was unrelated to the service-connected skin condition, it was unrelated to treatment for the skin condition, Agent Orange exposure, or to negligent treatment on the part of VA. In a February 2013 VA medical opinion, the VA examiner indicated that he reviewed the entirety of the claims file and examined the Veteran. Concerning a statement of a VA examiner in 1998 that osteoarthritis could be associated with extensive pustular disease, the current VA examiner indicated that there was no medical basis for that statement. The examiner furthermore indicated that he did not find any evidence that VA treatment caused or aggravated any of the Veteran's joint problems. Many of the Veteran's joints were normal. Others were afflicted with mild arthritis that was a degenerative type of arthritis that was the result of repeated microtrauma over the years and was unrelated to the Veteran's service-connected skin condition. Likewise, any treatment on the part of VA did not cause the Veteran's joint problems. VA treatment did not cause arthritis as an unforeseeable consequence outside of the normal scope of risk for treatment of his skin condition. The examiner found no evidence that the Veteran had any additional disability due to negligent VA treatment, bad medical judgment, etc, and the Veteran had no permanent kidney disorder that that was caused by or made worse by bad medical judgment or negligence on the part of VA. In another February 2013 VA medical opinion, the VA examiner diagnosed bilateral knee chondromalacia, which was initially found in 1999. Current X-ray studies were normal with no evidence of arthritis. The examiner emphasized that the Veteran did not suffer from arthritis of the knees due to any cause. The chondromalacia was not due to service, the service-connected skin condition, medication used to treat the service-connected skin condition, Agent Orange, or negligent treatment on the part of VA. On February 2013 VA kidney examination, the examiner indicated that the only relevant diagnosis was hematuria due to sickle cell trait. The examiner also noted chronic kidney disease. He also had intermittent microscopic hematuria on two urinalyses over the previous six years. The examiner opined that the Veteran's hematuria was at least as likely as not due to the Veteran's sickle cell trait and not to the treatment received for the service-connected skin condition. The Veteran's chronic kidney disease was at least as likely as not due to hypertension. The microscopic hematuria was insignificant and was not causing the kidney disease. The term focal pyelonephritis meant a localized kidney infection of which there was no evidence at the present time. The kidney condition was unrelated to medication used to treat the service-connected skin condition. The kidney condition was not due to negligence on the part of VA, and there was no kidney condition from 1994 that was an unforeseeable result outside the normal risk for the treatment administered. On February 2013 VA hip and thigh examination, the examiner indicated that X-ray studies indicated that there was no arthritis of the hips. The examiner indicated that the Veteran did not have arthritis of the hips due to any cause. No abnormality of the hips was found on examination. On February 2013 VA eye examination, the only eye diagnosis other than congenital or developmental errors of refraction was cataracts. The Board notes that diabetes mellitus without retinopathy was documented as well. Uncorrected distance vision was 20/50 bilaterally. Uncorrected near vision was "20/40 or better" bilaterally. Corrected distance vision was "20/40 or better" bilaterally. Corrected near vision was "20/40 or better" bilaterally. There was no diplopia or corneal irregularity. There was no visual field defect. The Veteran's cataracts were bilateral and preoperative. Some of the decrease in visual acuity was due to the cataracts. The examiner indicated that there was no evidence that an eye condition was caused by the service-connected skin condition or treatment for the service-connected skin condition. In the 1990's the Veteran was found to have myopia, a refractive eye condition that is corrected with glasses. On February 2013 VA back examination, the examiner diagnosed mild thoracic spine degenerative arthritis. The examiner opined that the mild degenerative changes were due to repeated microtrauma associated with the normal aging process. It was not related to the Veteran's skin condition, treatment for the skin condition, Agent Orange, or negligent treatment on the part of VA. It was unrelated to service. On February 2013 VA ankle examination, the examiner diagnosed no ankle disabilities. X-ray studies of the ankles were normal. The Veteran, however, complained of chronic ankle pain. The examiner found no objective evidence of an ankle disability on either the right or left. On February 2013 VA knee and lower leg examination, the examiner diagnosed bilateral chondromalacia diagnosed in 1999. Current X-ray studies of the knees were normal with no evidence of arthritis. The Veteran, however, had knee pain and occasional swelling. The examiner indicated that the Veteran did not have arthritis of the knees due to any cause. The chondromalacia was not due to service, a service-connected skin condition, medical used in the treatment of the service-connected skin condition, Agent Orange, or negligent treatment. Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes that 38 C.F.R. § 3.303(b) applies herein because arthritis is a chronic disease under 38 C.F.R. § 3.309(a). See generally Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is not generally established for refractive error of the eye as it also is not a disease or injury within the meaning of applicable legislation providing compensation benefits. 38 C.F.R. § 3.303(c), 4.9 (2012). Refractive error of the eyes includes myopia, presbyopia, and astigmatism. Id.; VA Manual M21-MR1, Part III, Subpart IV, Chapter 4, Section B, Para. 10(d). Absent superimposed disease or injury, service connection may not be allowed for a congenital or developmental defect of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Parker v. Derwinski, 1 Vet. App. 522 (1991); McNeely v. Principi, 3 Vet. App. 357, 364 (1992). Thus, in the absence of some event of trauma, refractive error is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. §§ 3.303(c), 4.9 (congenital or developmental defects, refractive error of the eye, personality disorders, and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); see also VAOPGCPREC 82-90. The Board recognizes that VA's General Counsel, after studying 38 C.F.R. § 3.303(c), issued the interpretation, binding on the Board, that service connection may be granted for diseases of congenital, developmental, or familial origin if the evidence as a whole shows that manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. The VA General Counsel also has interpreted that a congenital defect can be subject to superimposed disease or injury, and if superimposed disease or injury occurs during military service, service-connection may be warranted for the resultant disability. VAOPGCPREC 82-90. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, and calculi of the kidney, cardiovascular-renal disease, or hypertension to a degree of 10 percent or more within one year from separation from service, such diseases may 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. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. A veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. For the purposes of this section, the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6). The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307. The presumption requires that a veteran actually stepped foot on land in Vietnam. Haas v. Peake, 525 F.3d 1168 (2008); VAOPGCPREC 27-97. The following diseases are deemed associated with herbicide exposure, under current VA regulation: chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The foregoing diseases shall be service connected if a veteran was exposed to an herbicide agent during active military, naval, or air service, if the requirements of 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C.A. §§ 501(a), 1116; 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). VA regulations specify that the last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 41,442 -41,449, and 61 Fed. Reg. 57,586-57,589 (1996). Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Under the version of 38 U.S.C.A. § 1151 in effect for claims filed prior to October 1, 1997, "[w]here any veteran suffers an injury or an aggravation of an injury, as a result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation . . . awarded under any of the laws administered by the Secretary, or as the result of having submitted to an examination under any such law, and not the result of such veteran's own willful misconduct, and such injury or aggravation results in additional disability to or the death of such veteran, disability or death compensation . . . shall be awarded in the same manner as if such disability, aggravation or death were service-connected." 38 U.S.C.A. § 1151 (West 1991). This version of the statute was interpreted by VA regulations as requiring a showing of evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instances of indicated fault on the part of VA, or the occurrence of an accident or an otherwise unforeseen event, to establish entitlement to 38 U.S.C.A. § 1151 benefits. See, e.g., 38 C.F.R. § 3.358(c)(3) (1994). This regulation was invalidated by the Court, in Gardner v. Derwinski, 1 Vet. App. 584 (1991). The Gardner decision was affirmed by both the United States Court of Appeals for the Federal Circuit, see Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), and the United States Supreme Court (Supreme Court), see Brown v. Gardner, 513 U.S. 115 (1994). The Supreme Court, in affirming the Court's decision, held that the statutory language of 38 U.S.C.A. § 1151 simply required a causal connection between VA hospitalization and additional disability, and that there need be no identification of "fault" on the part of VA. See, Brown, supra. 38 C.F.R. § 3.358 was amended in 1995 to conform to the Supreme Court decision. The amendment was effective November 25, 1991, the date that the Court issued the Gardner decision. 60 Fed. Reg. 14,222 (March 16, 1995). In particular, section (c)(3) of 38 C.F.R. § 3.358 was amended to remove the "fault" requirement which was struck down by the Supreme Court. 38 C.F.R. § 3.358(c)(1) provides that "[i]t will be necessary to show that the additional disability is actually the result of such disease or injury or an aggravation of an existing disease or injury and not merely coincidental therewith." Further, 38 C.F.R. § 3.358(b)(2) provides that compensation will not be payable for the continuance or natural progress of disease or injuries. 38 C.F.R. § 3.358(c)(3) provides that "[c]ompensation is not payable for the necessary consequences of medical or surgical treatment or examination properly administered with the express or implied consent of the veteran, or, in appropriate cases, the veteran's representative." "Necessary consequences" are those which are certain to result from, or were intended to result from, the examination or medical or surgical treatment administered." Under the amended version of 38 C.F.R. § 3.358, compensation is precluded where disability: (1) is not causally related to VA hospitalization or medical or surgical treatment, (2) is merely coincidental with the VA hospitalization or medical or surgical treatment, (3) is the continuance or natural progress of diseases or injuries for which VA hospitalization or medical or surgical treatment was authorized, or (4) is the certain or near certain result of the VA hospitalization or medical or surgical treatment. Where a causal connection exists, there is no willful misconduct, and the additional disability does not fall into one of the above-listed exceptions, the additional disability will be compensated as if service connected. 38 C.F.R. § 3.358(b), (c) (effective prior to October 1, 1997). In determining whether the Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran's condition after care or treatment is rendered. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. Merely showing that the Veteran received care or treatment and that the Veteran has an additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). VA received the current claim in July 1994, and it must be adjudicated in accordance with the earlier version of 38 U.S.C.A. § 1151. See VAOPGCPREC 40-97. Neither evidence of an unforeseen event nor evidence of VA negligence is required in order for this claim to be granted. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on a veteran's behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Arthritis of the joints The service treatment records do not show that the Veteran was treated for arthritis, or joint pain during active service. Records since 1979 have cited joint stiffness and eventually diagnoses of arthritis, polyarthritis, osteoarthritis, and degenerative arthritis. None of the medical records, private or VA, relate the Veteran's arthritis to his active service. The Board has reviewed all evidence in the claims file, including lay statements, research articles, supplemental articles, hearing transcripts, and all medical records. Regarding the Veteran's claim for service connection for arthritis of multiple joints, the Board finds that service connection is not warranted for anything other than the disabilities/joints already service connected (in this regard, when the Board addresses this issue, it will not be addressing the joints service connected in prior decisions). The Board notes that the service treatment records do not show, and the Veteran does not assert, that arthritis of any joint was incurred in service. Furthermore, the evidence does not reflect, and the Veteran does not assert, that arthritis had its onset in the first post-service year. Indeed, there is no indication of arthritis in the record until the latter part of the 1980's. As the Veteran separated from service in 1970, it follows that arthritis of multiple joints did not have its onset within the first post-service year. Thus, service connection for the claimed arthritic disability cannot be granted presumptively as a chronic disability. 38 C.F.R. §§ 3.307; 3.309(a). Furthermore, due to the long gap between service separation and the onset of arthritis, service connection for the claimed arthritis of multiple joints cannot be granted based on continuity of symptomatology. 38 C.F.R. § 3.303(b). The Board finds that a preponderance of the evidence is against the proposition that the Veteran's arthritis is otherwise related to service. The bulk of the evidence, and all of the evidence that is based on an examination of the Veteran as well as a review of the record, reveals that the Veteran's arthritis is not due to service in any way to include exposure to Agent Orange therein (the Board notes that the Veteran served in Vietnam and that exposure to herbicides is presumed). As such, the Board finds that arthritis of multiple joints is not directly related to service. 38 C.F.R. § 3.303(d). In this regard, the Board is aware that in August 1998, a VA examiner stated that Agent Orange exposure could have been a minor factor in the Veteran's arthritis. Such opinion has no probative value, as it is speculative. Obert, 5 Vet. App. at 33. That same examiner indicated that it was highly probable that service was a major contributor to the Veteran's disabilities. As the examiner did not specify the disability, this statement is too general to support a claim. Id. The Board notes that service connection for arthritis of multiple joints cannot be granted presumptively based on Agent Orange exposure because arthritis is not one of the disorders for which presumptive service connection is available based on herbicide exposure. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The Board also considered whether the Veteran's arthritis should be service connected on a secondary basis. Only one medical opinion, that contained in the VA examination report dated May 1998, stated that the disability could be associated with the underlying condition more than the treatment for it and that sometimes arthralgias could be associated with the extensive pustular disease from which the Veteran suffers. However, based on its wording, this opinion is speculative, at best, and a finding of service connection may not be based on a resort to speculation or remote possibility. Obert, supra. The Board notes, moreover, that the February 2013 examiner opined, after a review of the record and examination of the Veteran, that there was no medical basis for the conclusion that osteoarthritis could be associated with extensive pustular disease. The Board credits this opinion, as it is very thorough and based on a review of the evidence as a whole. See Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability). Because there is no probative evidence of any association between the Veteran's service-connected skin disability and arthritis, service connection on a secondary basis for the Veteran's claimed arthritis of multiple joints is denied. 38 C.F.R. § 3.310; Wallin, supra. The Board considered all lay statements from the Veteran and his acquaintances as well as the transcripts of all hearings. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), determining the etiology of arthritis in any of its many forms falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As such, the lay evidence from the Veteran and others is not competent and does not, therefore, outweigh the competent and probative medical evidence herein. The weight of the competent medical evidence demonstrates that the Veteran's arthritis of multiple joints was not present in service or for many years thereafter, and it was not caused by any incident of service, including claimed Agent Orange exposure in Vietnam, and was not caused or worsened by his service-connected skin disability. Arthritis of multiple joints was not incurred in or aggravated by service, nor is it secondary to a service-connected skin disorder . In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, Alemany, supra. For a successful claim under 38 U.S.C.A. § 1151, in effect for claims filed prior to October 1, 1997, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. In this case, the Veteran has been diagnosed with several different types of arthritis including degenerative arthritis, polyarthritis, and osteoarthritis. Regarding the § 1151 claim for arthritis, the March 1998 and January 1999 examiners stated that the osteoarthritic changes were not secondary to medication. The March 1998 examiner specifically stated that if such changes were secondary to a form of medication, there would be a consistent symmetrical pattern throughout the Veteran's entire joint system. The May 2009 VA expert stated that to her knowledge, arthritis is not caused by steroids or antibiotics, and that the arthritis is less likely as not related to the medication used to treat the service connected skin condition. In the August 2009 addendum, the examiner said that osteoarthritis, polyarthritis, is less likely as not related to the use of steroids in service as she could not find any evidence to substantiate the relationship between arthritis and the use of steroids in the literature. On the various VA joint examinations in February 2013, the examiner opined that degenerative changes were due to repeated microtrauma resulting from the normal aging process. They was not due to the Veteran's skin condition or treatment for the skin condition and were not due to negligent treatment on the part of VA. In support of the Veteran's claim for § 1151 compensation for arthritis is the May 1998 examination, which indicates that osteoarthritis could be associated with the underlying condition more than the treatment for it. However, this opinion is speculative at best and carries no probative weight. Obert, supra. Also, the letter from Dr. C.N. implies a possible connection between osteoarthritis and steroid therapy; however, Dr. C.N. provided no rationale for his assumption, admitted he did not have all of the Veteran's records for review, and more importantly, his opinion was geared toward the etiology of the Veteran's TMJ disability. This opinion is general and not based on a thorough review of the record, and is therefore not probative. Id.; Prejean,13 Vet. App. at 448-9 (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.). The January 1999 examiner indicated a possible nexus between joint problems and steroids. Specifically, he stated that large doses of steroids caused avascular necrosis of the hips, knees, and shoulder, and that it could not be proven or disproven that the similar mechanism could have occurred in the Veteran's TMJ. However, the Veteran does not have avascular necrosis, thus this opinion, though appearing to link joint problems such as arthritis to steroid treatment, has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion that is based upon an inaccurate factual premise has no probative value). Finally, Dr. S-L indicates that a review of the medical literature shows a link between steroid use and osteoarthritis, supporting the Veteran's claim for § 1151 compensation for arthritis. However, it is unclear as to Dr. S-L.'s background and credentials, and more importantly, Dr. S-L. did not include or identify the medical literature consulted. The VA expert opinion clearly states that the literature in the claims file, which is specifically identified in her report, does not support a link between steroids and arthritis. The Board notes that the November 2011 opinion authored by Dr. Left-S is not pertinent to arthritis and is therefore not relevant herein. The Board has reviewed the evidence, including lay statements, and finds that the VA examination reports, specifically the May 2009 expert opinion, the August 2009 addendum, and the February 2013 VA examination reports are more persuasive regarding this issue. Indeed, the Board has explained above why evidence to the contrary is not probative of the question at hand. The VA examiner is an expert in her field. She reviewed the claims file, recited medical history in the reports, indicated review of medical literature, and provide a rationale for her opinions. The February 2013 VA examiner reviewed the claims file in its entirety and examined the Veteran in reaching his conclusions. Dr. S.-L. did not identify medical literature consulted, and other potential nexus opinions are either speculative or not supported by rationale. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (noting that the Board may appropriately favor the opinion of one competent medical authority over another). Therefore, based upon the thorough opinions provided by the VA examiners and expert, the Board finds that the preponderance of the evidence weighs against a finding that the medications used to treat the service connected skin condition caused the Veteran's arthritis of the joints, and compensation under 38 U.S.C.A. § 1151 is denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany, supra. Loss of vision The service treatment records do not show complaints of or treatment for loss of vision. The June 1966 entrance examination report noted that the Veteran had 20/20 vision in both eyes without correction. The February 1970 separation examination report noted that the he had 20/15 vision in both eyes without correction. The first clinical evidence of any eye or loss of vision disability is pursuant to a VA ophthalmological examination in April 1996. At that time, the Veteran's vision in both eyes was 20/200, uncorrected and 20/25, corrected. The diagnoses included corneal scar, possibly leading edge of pterygium and macular mottling, cause unknown, not influencing vision. A more recent March 1998 VA ophthalmological examination report noted that the Veteran had 20/400 vision in both eyes, uncorrected and 20/25 vision, corrected. The examiner noted that there was a pterygium on the left eye. The diagnosis was myopia. In a May 1998 report, a VA examiner indicated that he was not familiar with any reason for loss of vision in the treatments that he found on reviewing the Veteran's chart from the early 1970's to 1997. The May 2009 VA expert report states that she found no indication of loss of vision and that the Veteran has normal corrected visual acuity. She further stated that the claimed vision loss is less likely as not a result of medication used to treat his service connected skin disorder. In February 2013, the only eye diagnosis other than congenital or developmental errors of refraction was cataracts. There was also a notation of diabetes mellitus without retinopathy. Uncorrected distance vision was 20/50 bilaterally. Uncorrected near vision was "20/40 or better" bilaterally. Corrected distance vision was "20/40 or better" bilaterally. Corrected near vision was "20/40 or better" bilaterally. There was no diplopia or corneal irregularity. There was no visual field defect. The Veteran's cataracts were bilateral and preoperative. Some of the decrease in visual acuity was due to the cataracts. The examiner opined that there was no evidence that an eye condition was caused by the service-connected skin condition or treatment for the service-connected skin condition. The Board observes that the Veteran was diagnosed with myopia in March 1998. Myopia (nearsightedness) is a type of refractive error. Refractive error of the eyes is not a disease or injury within the meaning of applicable legislation pertaining to compensation benefits. See generally 38 C.F.R. §§ 3.303(c), 4.9. Additionally, although the records indicate that the Veteran has suffered some loss of vision, at least in terms of uncorrected vision, he has not been shown to have a disease or injury causing such loss of vision. A March 1998 examination report did note that the Veteran had a pterygium on the left eye and an April 1996 examination report indicated that he had a corneal scar, possibly the leading edge of a pterygium and macular mottling, cause unknown, that was not influencing his vision. More recently, preoperative cataracts were said to have had some impact upon the Veteran's ability to see. Obviously, the cataracts are not a permanent condition in that they are correctable via surgery. For compensation under 38 U.S.C.A. § 1151 for loss of vision, claimed as due to VA medical treatment for a service-connected skin disability, the Board notes that there is no competent medical evidence suggesting that any current loss of vision was caused or worsened by VA treatment for the Veteran's skin disability. As noted above, the examiner pursuant to a May 1998 report specifically commented that he was not familiar with any reason for loss of vision in the treatments that he found on reviewing the Veteran's chart from the early 1970's to 1997. The May 2009 expert said that the Veteran's claimed vision loss is less likely as not related to VA treatment. The February 2013 VA examiner opined that there was no sign of a relationship between any disorder of the eyes and the Veteran's service-connected skin condition or medication taken for its treatment, providing highly probative evidence against this claim. Compensation under 38 U.S.C.A. § 1151 requires that there be additional disability as the result of VA medical treatment. The Board considered the Veteran's statements and testimony, however the Board cannot rely on the Veteran's lay representations herein, as he is not competent to provide evidence regarding the origins of ophthalmological disorders because such are complex matters beyond the ken of the lay person. See Jandreau, 492 F.3d 1377 n.4 ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). The competent medical evidence establishes that any current loss of vision, either in whole or in part, is not due to VA medical treatment, to include VA medical treatment for the Veteran's service-connected skin disability. Consequently, the criteria for compensation under 38 U.S.C.A. § 1151 have not been met. As the preponderance of the competent evidence is against the claim for compensation under 38 U.S.C.A. § 1151, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.1-2; Alemany, supra. Kidney disorder (to include hematuria) The Veteran's service medical records indicate that he was seen for complaints of burning on urination in March 1968. A March 1968 treatment entry noted that the Veteran was discharged from the hospital after a urinary tract infection and another March 1968 entry related a diagnosis of pyelonephritis, acute. At the time of the February 1970 separation examination, it was noted that the Veteran had pyelonephritis in March 1968 and that he was hospitalized for one week with a good recovery. The examination report included notations that the Veteran's genitourinary system was normal. The first clinical indication of any possible kidney disability or hematuria subsequent to service, is pursuant to a June 1988 VA treatment entry which noted that the Veteran complained intermittent dysuria. The diagnosis at that time, was prostatitis. A May 1989 entry noted that the Veteran complained of pain in the right kidney area and reported that he had some burning with urination as well as some blood about 12 weeks earlier. Subsequent May 1989 entries referred to hematuria and focal polynephritis. Additionally, a January 1994 VA medical examination report related diagnoses including bleeding from the penis with the examiner noting that he had no medical records do substantiate those claims. The Board notes that a March 1996 VA general medical examination report related diagnoses including renal disease, not found. A May 1998 examination report indicated an impression which included recurrent hematuria secondary to a sickle cell trait, unrelated to Dapsone therapy. The examiner commented that it was well known that a sickle cell trait at times manifested itself as hematuria. The examiner also stated that the Veteran did not have documented kidney disease and that the Veteran did not have compromised renal function at any time. Pursuant to a May 1998 report, a VA examiner stated that he knew of no reasons why someone would have kidney problems from the Veteran's treatment except that he did have extensive hemolysis at one time. The examiner stated that he knew of no kidney problem the Veteran had from that disability. The Board further notes that a February 1999 VA genitourinary examination report indicated an impression of history of gross hematuria with negative cystoscopies in the past. The examiner stated that he knew of no definitive association between Dapsone therapy in hematuria. In an April 1999 addendum, the examiner stated that in his opinion, the Veteran had failed to document any significant hematuria. The examiner commented that he was unable to give a diagnosis for the Veteran's gross hematuria because he was not sure hematuria existed. He stated that he had attempted to perform diagnostic tests on the Veteran, but the Veteran had failed to report for the tests. In the May 2009 examination, the examiner noted that VA outpatient treatment records indicated microscopic hematuria in June 2007. She stated that the Veteran has trace microscopic hematuria, which is not significant. She stated that kidney functions are normal, and that any claimed kidney disorder is less likely as not related to treatment for a skin disorder. A June 2010 VA progress note indicated a diagnosis of a urinary tract infection with hematuria. The hematuria was expected to resolve gradually. Antibiotics were prescribed. The February 2013 VA examiner indicated the Veteran's hematuria was due to sickle cell trait and unrelated to kidney disease. He noted chronic kidney disease that was at least as likely as no due to hypertension. There was no evidence of a kidney infection. The kidney condition, according to the VA examiner, was unrelated to medication used to treat the service-connected skin condition. The Board has taken into account the Veteran's written communications and testimony. However, the Board cannot rely on the Veteran's representations regarding the presence and/or nature of a renal disorder because these sorts of medical conditions are of a complex nature and beyond the visuals of the lay person. See Jandreau, 492 F.3d 1377 n.4 ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). The competent medical evidence reflects that hematuria is due to a genetic disorder, and compensation in most circumstances is not available for genetic and developmental disorders. 38 C.F.R. § 3.303(c). In any event, the Veteran's hematuria is not due to or a sign of a kidney disorder. Throughout most of this appeal, the Veteran's kidneys were assessed as normal. The most recent evidence reveals chronic kidney disease due to hypertension. The Board notes that service connection is not in effect for hypertension. Compensation under 38 U.S.C.A. § 1151 requires that there be additional disability as the result of VA medical treatment. The competent medical evidence establishes that the current chronic kidney disease is not due to VA medical treatment, to include VA medical treatment for the Veteran's service-connected skin disability. Rather, it is the result of the Veteran's nonservice-connected hypertension. Consequently, the criteria for compensation under 38 U.S.C.A. § 1151 have not been met. As the preponderance of the competent evidence is against the claim for compensation under 38 U.S.C.A. § 1151, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany, supra. Veterans Claims Assistance Act of 2000 (VCAA) VCAA and implementing regulations impose obligations on VA to provide those claiming VA benefits with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dings v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (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. In a May 2008 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate claims as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective date of a claim. Any defect as to the timing of the VCAA notice was cured because the RO readjudicated the claims on several occasions to include in a March 2013 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and re-adjudicating the claim in the form of a statement of the case to cure timing of notification defect). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The record contains the service treatment records, VA clinical records, private medical records, Social Security Administration records, the Veteran's statements to include hearing testimony, lay statements, and relevant VA examination reports. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the numerous VA medical opinions obtained in this case are adequate in the aggregate. The opinions provided considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues herein has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording VA examinations. The types of evidence obtained by VA are enumerated above. These is no indication that there is any outstanding evidence that is relevant and that has not been obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Beyond the above, the Board must note that this case has been ongoing for more than 20 years for reasons which have not always been within the scope of the Board to control (for example, the July 2003 joint motion, in which the Court sent the case back to address VCAA notice that did not exist at the time the RO address the Veteran's initial claims in light of Court determination that did not exist at the time the Board addressed the case and delays requested by the Veteran's attorney). In addition, the Veteran has a 100% disability rating in effect from 1996 (17 years). It would appear very unclear as to why any issue would be re-litigated (once gain) that did not impact the evaluation of the Veteran's 100% disability evaluation. Further, based on procedural view of this case, and its many claims files, it is important to note that the VA has been placed in the difficult role in many instances of disproving the Veteran's causation claims based on information supplied by the Veteran from sources of highly limited probative value. See Evans v. Shinseki, 25 Vet. App. 7, 14 (2011) (stating that the VA system is "veteran-friendly" and "non-adversarial"); Kouvaris v. Shinseki, 22 Vet. App. 377, 381 (2009) (noting that the veterans benefits system is a "veteran-friendly" system). Even today, decades after ligation in this case began, it is important for the Veteran to understand that the question of whether any of his disabilities have any connection to service from June 1966 to April 1970 is, at best, unclear. It is only with the giving of the benefit-of-the-doubt that the Veteran has prevailed in so many of his claims. In this regard, it is very important for the Veteran understand that many of the of the claims granted have been based on evidence of highly limited probative value. In any event, further development of this case does not serve the interests of the Veteran or the VA for reasons cited above. Finally, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts 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. The Board finds that the Veteran is not prejudiced by any omissions in this regard. He had a hearing in 2001 before a VLJ who is no longer employed by the Board. As such, he was offered another hearing. He did not take advantage of that opportunity. Thus, he forwent the opportunity to obtain the type of information from a VLJ mandated by the Court in Bryant, issued 11 years after the hearing. The Veteran's attorney is well aware of the evidence needed to prevail in this case. ORDER Service connection for arthritis of multiple joints is denied. Entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for the following conditions: arthritis of multiple joints, loss of vision, and a kidney disorder (including hematuria), as a result of VA treatment for a skin disorder, is denied. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs