Citation Nr: 1319223 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 10-26 746 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for meibomianitis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to March 1995 and March 2004 to February 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Veteran had perfected an appeal with respect to an additional issue of entitlement to service connection for actinic keratosis. However, a March 2012 rating decision granted service connection for such disorder. As such is grant of the full benefit sought on appeal, the issue of entitlement to service connection for actinic keratosis is not properly before the Board and the only issue remaining on appeal is as listed on the title page. In May 2012, the Veteran testified before the undersigned Veterans Law Judge sitting at the RO. A copy of the hearing transcript is of record and has been reviewed. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. Meibomianitis is not shown to be causally or etiologically related to any disease, injury, or incident during the Veteran's first period of active duty. 2. There is clear and unmistakable evidence that meibomianitis pre-existed the Veteran's entrance to his second period of active duty. 3. There is clear and unmistakable evidence that the Veteran's meibomianitis did not permanently increase in severity beyond the nature progression of the disease during the Veteran's second period of active duty. 4. The competent and probative evidence of record fails to show that the Veteran's pre-existing meibomianitis was aggravated by his second period of active duty. CONCLUSIONS OF LAW 1. Meibomianitis was not incurred in during the Veteran's first period of active duty. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The presumption of soundness is rebutted and meibomianitis pre-existed the Veteran's entry to his second period of active duty. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304(b) (2012). 3. Meibomianitis was not aggravated by the Veteran's second period of active duty. 38 U.S.C.A. §§ 1110, 1153, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2008 letter, sent prior to the initial unfavorable decision issued in March 2009, advised the Veteran of the evidence and information necessary to substantiate his service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, this letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's treatment records have been obtained and considered. In this regard, he testified that all of his reports of treatment at the Phoenix Indian Medical Center had been obtained by VA. Moreover, he has not identified any additional, outstanding records that have not been requested or obtained. In addition, the Veteran was afforded VA examinations in November 2010 and May 2012 and the Board obtained a medical expert opinion from the Veterans Health Administration (VHA) in accordance with VHA Directive 2010-044 in March 2013. The Board finds that the VA examinations and etiological opinions are adequate to decide the issue. The examinations are predicated on interview with the Veteran as well as physical examination and, further, the May 2012 VA examiner and March 2013 VHA physician noted review of the record, to include the Veteran's service treatment records. The ultimate opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided complete rationales, relying on, and citing to, the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In this regard, the Board notes that the Veteran's representative alleged in a May 2013 brief that the March 2013 VHA opinion was inadequate in that she misunderstood the inquiry and misstated that meibomianitis was not aggravated by service. However, the Board finds that the examiner did, in fact, understand the Board's inquiry and offered a responsive opinion. Specifically, as will be discussed herein, while the physician acknowledged that the Veteran experienced symptoms of his meibomianitis during service due to various conditions such as extensive computer use, exposure to low humidity and air pollution, and medications to lower blood pressure and antihistamines to control symptoms of allergic rhinitis, she found that the underlying disability was not aggravated beyond the natural progression during service. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. Additionally, in May 2012, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the May 2012 hearing, the Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the onset of the Veteran's meibomianitis and claimed aggravation of symptoms during service. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, and as indicated above, the hearing discussions did not reveal any evidence that might be available that had not been submitted. Furthermore, the Board sought an expert opinion in this case in order to resolve the issue regarding the alleged aggravation of the Veteran's meibomianitis. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Thus, the Board finds that VA has fully satisfied the duty to notify and assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis The Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. As noted in the Introduction, the Virtual VA file does not contain any evidence or correspondence pertinent to the matter at hand. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit recently clarified that the law providing for awards of service connection based on continuity of symptomatology only pertains to "chronic" diseases under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this regard, meibomianitis is not recognized under VA regulations as a chronic disease. When an issue is raised as to whether the disorder claimed by the Veteran pre-existed service, the governing law provides that every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities or disorders noted at the time of examination, acceptance, and enrollment into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that (1) an injury or disease existed before acceptance and enrollment into service (2) and was not aggravated by such service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). This statutory provision is referred to as the "presumption of soundness." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, No. 11-2355, 2012 WL 5233422, at *6 (Vet. App. October 24, 2012); Bagby, 1 Vet. App. at 227; see also 38 C.F.R. § 3.304(b) ("Only such conditions as are recorded in examination reports are considered as noted."). This presumption is only rebutted where the evidence clearly and unmistakably shows that the Veteran's disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. The two parts of this rebuttal standard are referred to as the "preexistence prong" and the "aggravation prong." Horn, 25 Vet. App. at 234. The aggravation prong may be met by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096; see also 38 U.S.C. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits, and, conversely, where the presumption is not rebutted, the Veteran's claim is one for service connection, and not aggravation. Wagner, 370 F.3d at 1096. Accordingly, no deduction for the degree of disability existing at the time of entrance shall be made if a rating is awarded. Cf. 38 C.F.R. § 3.322 ("In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service..."). Aggravation is not conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b) ; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Thus, "a lasting worsening of the condition-that is, a worsening that existed not only at the time of separation but one that still exists currently-is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997); Verdon v. Brown, 8 Vet. App. 529, 538 (1996). In Smith v. Shinseki, 24 Vet. App. 40, 45 (2010), it was clarified that the presumption applies when a Veteran has been "examined, accepted, and enrolled for service," and where that examination revealed no "defects, infirmities, or disorders." 38 U.S.C. § 1111. Plainly, the statute requires that there be an examination prior to entry into the period of service on which the claim is based-here, the second period of active duty. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected" (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). When there is an approximate balance in the 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(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. The Veteran, to include in sworn testimony, does not assert that the eye disorder for which service connection is claimed, meibomianitis (an inflammation of the meibomian glands, a group of oil-secreting glands in the eyelids), is the direct result of his first period of active duty, but instead was first manifested between his two periods of active duty and was aggravated by his second period of active duty. In this regard, the evidence does not show, or suggest, that meibomianitis is causally or etiologically related to any disease, injury, or incident during the Veteran's first period of active duty. Specifically, review of the clinical reports from the first period of active duty, to include reports from medical histories collected in August 1994 and January 1995, note treatment for viral conjunctivitis in March 1973 and October 1973, but do not reflect evidence of a chronic eye disorder, to include meibomianitis. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, the Veteran testified that his meibomianitis was first diagnosed in April 2002, which was between his first and second period of active duty. May 2012 Hearing Transcript (Transcript), page 3. Review of the medical evidence of record confirms that the first clinical reference to this condition is contained on an eye clinic report dated in April 2002. With respect to the nature of the meibomianitis that existed prior to the Veteran's second period of active duty, the Veteran testified that he was using one box of "Refresh Plus" eye drops for this condition every two or three months. Transcript, page 3. Symptoms prior to service were said to include itching of the eyelids and burning and dryness in the eyes. Id., page 4. He also described having occasional sensitivity to the light. Id. He testified that the condition became worse during service, and that in approximately July 2005, he was prescribed three boxes of eye drops at a time because he was using them more. Id. The Veteran testified that he had to use the eye drops more during his second period of active duty due to exposure to construction dust and, because of problems with the air conditioning system, large fans that caused increased dryness in his eyes. Transcript, pages 5-6. He also said that in approximately October 2005, he developed a conjunctive cyst that eventually resolved in 2006. Transcript, page 6. As to current symptoms, he testified that he has to use a box of eye drops every month, whereas a box used to last three months. Id. He also testified that the condition had become worse the past few days before the hearing due to wind and dust. Transcript, page 8. Reviewing the pertinent clinical evidence of record prior to the second period of active duty, following the initial diagnosis of meibomianitis in April 2002, at which time the Veteran was prescribed with one box of "Refresh Plus" eye drops, a May 2002 eye clinic report noted that the Veteran was doing better due to the eye drops. A July 2003 eye clinic report reflects complaints of eye dryness and that the Veteran's eye drops had run out. He was prescribed a three box refill of eye drops at that time. August 2003 and October 2003 eye clinic reports reflect no complaints of dry eyes and do not otherwise refer to meibomianitis. Reports from a medical history (DD Form 2807-1) dated in October 2003 and apparently completed in January 2004 noted the presence of an "[e]ye disorder or trouble," with a reference to nearsightedness and astigmatism, but not meibomianitis. During the Veteran's second period of active duty, an October 2005 eye clinic report reflects treatment for a conjunctive cyst in the right eye. A January 2006 eye clinic report does not reflect any complains related to meibomianitis. The examination of the eyes at the January 2006 VA examination was negative. The medical history collected at that time referenced an unspecified "[e]ye disorder or trouble." After the Veteran's second period of active service, a February 2007 eye clinic report did not reference meibomianitis, but did discuss "unexplained" pain in the right eye. Clinical reports dated through September 2007 contain reference to the continuing prescription of eye drops from March 2007. At the November 2010 VA eye examination, the history of meibomianitis being diagnosed between the two periods of active duty was recorded, and it was noted that this condition necessitated that the Veteran be prescribed artificial tears, warm compresses, and lid scrubs. The Veteran reported that such treatment was helpful, but that he still had problems with dryness, worse some times than others. Following the examination, the optometrist concluded that the Veteran's meibomianitis was not caused by or the result of long hours of reading/staring at a computer without proper lighting or temperature controls during active duty. The examiner noted that clogged meibomian glands that cause meibomianitis may be the result of a proliferation of bacteria from the lid and lash area (blepharitis) and rosacea. She explained that the Veteran did not have rosacea, but that meibomianitis and blepharitis exacerbate and "may even cause" dry eyes. However, she stated that while staring at a computer screen for long hours may exacerbate dry eyes or cause short periods of dry eyes, such activity did not fundamentally cause the condition. (Emphasis added). The examiner documented that this opinion was based on a review of the claims file, to include the medical records from service. At a May 2012 VA eye examination, the examiner found that it was unlikely that long hours on duty of reading/staring at a computer with without proper lighting or temperature controls during service caused the Veteran's blepharitis/meibomianitis. The examiner documented that this opinion was based on a review of the claims file. The March 2013 expert opinion, documented to have been based on a review of the claims file, noted that, as meibomianitis was diagnosed in April 2002, the condition "clearly and unmistakably pre-existed" the Veteran's second period of active duty. She concluded that meibomianitis was not aggravated beyond its natural progression during service. (Emphasis added). Her rationale was that meibomianitis was due to inflammation of the meibomianitis glands and that none of the following which occurred during service would have caused inflammation of the meibomianitis glands: extensive computer use; exposure to low humidity and air pollution; or his blood pressure medication (hydrochlorothiazide) or his antihistamines (Allegra and Chlorpheniramine) for treatment of allergic rhinitis. She concluded by stating that it was "as likely as not that the Veteran's meibomianitis has no causal relation to any incident of service because meibomianitis is an inflammation of the meibomian glands of unknown origin." The examiner did note that hydrochlorothiazide and antihistamine medications had a "drying effect" such that more tears would be needed to relieve dry eye symptoms associated with meibomianitis and that symptoms of dry eyes can result from long hours at the computer, fans, and dusty air. (Emphasis added). Bearing in mind the theory of entitlement raised by the Veteran (that the second period of active duty aggravated pre-existing meibomianitis) and applying the pertinent legal criteria to the facts summarized above, while it is not clear if it represents the type of pre-service clinical findings contemplated by Smith, supra, the Board will afford the Veteran the benefit of accepting that the fact that the medical history completed in January 2004 prior to the Veteran's secondary period of service is equivalent to a finding that meibomianitis was not shown upon being "examined, accepted, and enrolled" for his second period of active duty so as to trigger the presumption of soundness at 38 U.S.C. § 1111. As such, the matter for consideration is whether this presumption has been rebutted. Turning first to the "preexistence prong," the Board finds that there is clear and unmistakable evidence that the Veteran's meibomianitis existed prior to the Veteran's second period of active duty. As support for this determination, attention is directed to the April 2002 eye clinic report diagnosing the condition, the May 2002 and July 2003 eye clinic reports referencing treatment for this condition, and the conclusion in the March 2013 expert's opinion that the condition clearly and unmistakably pre-existed service. In this regard, the March 2013 VHA opinion included a clear conclusion with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, the Board accords it great probative value. Moreover, the Veteran offered sworn testimony that the condition existed and was symptomatic prior to his second period of active duty. As to the "aggravation prong" the Board finds that there is clear and unmistakable evidence that the underlying disability associated with meibomianitis, in contrast to mere symptoms, that existed prior to the Veteran's second period of active duty did not increase in severity beyond the natural progression of the disease during the this period of service. The most probative evidence to this determination is the March 2013 VA medical expert's opinion that meibomianitis was not aggravated beyond its natural progression during service because the condition is due to inflammation of the meibomian glands and this underlying condition had no etiologic relation to service. In this regard, the March 2013 VHA opinion included a clear conclusion with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, the Board accords it great probative value. While the March 2013 opinion did, as set forth above, comment on the factors during service that may have contributed to dryness of the eyes resulting from meibomianitis, as noted, to the extent the opinion might suggest an increase during service in symptoms of dry eyes, as opposed to underling disability, during service, they do not describe "aggravation" for the purposes of a grant of service connection. Jensen, supra; Green, supra; Hunt, supra. In this regard, the Veteran's assertions as to an increase in disability during service are almost entirely based on the fact that he required an increase in his eye drop prescriptions during service for symptoms during service (dry and itchy eyes, etc.) that he clams persists to this day. However, review of the "medication lists" of record that reflect prescriptions for eye drops from January 2004 to March 2007 do not appear to support the Veteran's assertion as to the initial need for increased eye drops during the second period of active service. Even accepting the credibility and accuracy of these statements, again, to the extent they merely describe an increase in symptoms, as opposed to underling disability, during service, they do not describe "aggravation" for the purposes of a grant of service connection. Id. Furthermore, the reports from the visits to the eye clinic during the Veteran's second period of service dated in October 2005 and January 2006 simply do not reflect treatment for symptoms or evidence of meibomianitis. While there was, as indicated above, reference in October 2005 to treatment for a cyst, the examination of the eyes conducted upon separation from the Veteran's second period of active duty in January 2006 was negative for cyst or any other condition of the eyes, and the medical history at that time, albeit referencing a "disorder or trouble" in the eyes, did not reflect any specific reference to cysts in the eye or otherwise refer to the existence of symptoms of meibomianitis. The Veteran also essentially testified that his eye cysts resolved, with the exception of one recurrence. Transcript, page 10-11. Also of significance are the VA medical opinions rendered in November 2010 and May 2012 that dissociated the Veteran's meibomianitis from his service, based on a review of the clinical evidence contained in the claims file and clinical evaluations (which did not reveal recurrence of a cyst). Moreover, there is no medical opinion of record to contradict these conclusions, or the conclusion by the VA medical expert's March 2013 opinion. The Board accepts these opinions as being the most probative medical evidence on the subject, as they were based on a review of the pertinent medical records and contained detailed rationale. See Nieves-Rodriguez, supra; Stefl, supra. The Board has considered the Veteran's contention that a relationship exists between his meibomianitis and service. In this capacity, the Board finds that, while the Veteran is competent to attest to his symptomatology related to his eyes, he is not competent to provide an opinion that the underlying pathology of his meibomianitis was aggravated by service, or is otherwise related thereto, as he does not have the requisite medical expertise to render such an opinion. See Woehlaert, supra. Specifically, the question of aggravation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Therefore, based on the November 2010, May 2012, and March 2013 VA opinions, the Board finds that there is clear and unmistakable evidence that the Veteran's meibomianitis did not permanently increase in severity beyond the natural progression in service. As such, the Board concludes that there is clear and unmistakable evidence that the Veteran's meibomianitis existed prior to service and was not aggravated by service. Consequently, the presumption of soundness has been rebutted and the Veteran's meibomianitis pre-existed his second period of active duty. Additionally, for the same reasons discussed above, the Board finds that, based on the competent and probative evidence of record, to specifically include the November 2010, May 2012, and March 2013 VA opinions, the Veteran's pre-existing meibomianitis was not aggravated by his military service. The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for meibomianitis. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for meibomianitis is denied. ___________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs