Citation Nr: 1319630 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-36 577 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial compensable disability rating for a skin disability, manifested as tinea pedis and onychomycosis of the feet. 2. Entitlement to an initial rating in excess of 10 percent for diabetic retinopathy prior to February 9, 2012, and in excess of 20 percent thereafter. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1968 to October 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from three rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. An October 2006 decision of the VA RO granted service connection for diabetic retinopathy with an initial evaluation of 10 percent effective February 11, 2004. A December 2006 decision of the VA RO granted service connection for tinea pedis and onychomycosis of the feet with an initial evaluation of 0 percent effective February 11, 2004. A January 2010 decision of the VA RO denied service connection for hypertension. In July 2011, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the VA Central Office in Washington, D.C.; a transcript of that hearing is of record. In an October 2011 decision, the Board granted service connection for hypertension, which constituted a full grant of that portion of the appeal. The Board also remanded the issues of higher ratings for a skin disability and diabetic retinopathy for further development. During the course of the appeal, by rating decision in July 2012, the RO granted an increased 20 percent disability rating for diabetic retinopathy, effective from February 9, 2012. However, inasmuch as a higher rating is available for diabetic retinopathy, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating remains viable on appeal. Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). Subsequent to the issuance of the last Supplemental Statement of the Case, the Veteran submitted additional evidence directly to the Board. In a May 2013 brief located in the Virtual VA file, the Veteran's accredited representative waived initial RO consideration of the newly submitted evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The issues of entitlement to increased ratings for diabetes mellitus and peripheral neuropathy of the lower extremities have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the period of appeal, the Veteran's service-connected tinea pedis and onychomycosis of the feet were manifested by complaints of itching and a rash without the requirement of systemic therapy such as corticosteroids or other immunosuppressive drugs at any time, and the weight of the evidence of record does not reflect that the Veteran's tinea pedis and onychomycosis covers at least 5 percent of the entire body or at least 5 percent of exposed areas affected. 2. Throughout the period of appeal, the Veteran's diabetic retinopathy was manifested by corrected visual acuity of no worse than 20/200 in the right eye and 20/40 in the left eye; with no clinical findings of impairment of field vision shown. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for service-connected tinea pedis and onychomycosis of the feet have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Code 7806 (2012). 2. Extending every reasonable doubt to the Veteran, the criteria for a disability rating of 20 percent, but no higher, for service-connected diabetic retinopathy have been met throughout the period of appeal. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.84a, Diagnostic Code 6077 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Stegall Concerns In October 2011, the Board remanded the appeal to the RO, via the Appeals Management Center, for further development. The Board instructed the RO to schedule the Veteran for VA examinations for his eyes and his feet. The Veteran underwent the requested VA examinations in February 2012. As such, the Board finds that there has been substantial compliance with the requirements articulated in the Board's prior remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. The Veterans Claims Assistance Act (VCAA) With regard to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the Veterans Claims Assistance Act of 2000 (VCAA), when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). For initial rating claims, where service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As noted above, the appellant also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claims that were lacking to substantiate the claims for benefits, and suggested the submission of evidence that would be beneficial to the appellant's claims. Significantly, neither the appellant nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the appellant, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also concludes that VA's duty to assist has been satisfied. All of the Veteran's VA and private treatment records have been obtained to the extent possible and associated with the claims file. The Veteran has at no time referenced any further outstanding records that he wanted VA to obtain. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with VA examinations with regard to his service-connected skin disability and diabetic retinopathy, most recently in February 2012. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There is no objective evidence indicating that there has been a material change in the severity of either service-connected disability since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The report of these examinations reflect that each examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate testing, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The information obtained during these examinations are sufficient to rate the Veteran's disabilities under the appropriate diagnostic criteria. In light of the foregoing, the Board concludes that this examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). III. Increased Initial Rating A. General Law and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. B. Skin Disability, Manifested as Tinea Pedis and Onychomycosis of the Feet The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Service connection for tinea pedis and onychomycosis of the feet was originally granted in a December 2006 rating decision with a noncompensable disability rating under Diagnostic Code 7813. Diagnostic Code 7813, for dermatophytosis (ringworm: of body, tinea corporis; of heat, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris), specifies that the disability is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. The Board acknowledges that 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 were amended, effective from October 23, 2008. Indeed, the Veteran's accredited representative has suggested that the Veteran's skin disability be evaluated under diagnostic criteria for scars. However, as reviewed below, the medical evidence of record reflects that the skin disability in question is tinea pedis and onychomycosis of the feet-not a disfigurement of the head, face, or neck; or a scar. In October 2006, a VA examiner indicated that tinea pedis and onychomycosis were fungal conditions. Additionally, the February 2012 VA examiner specifically indicated that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck. As such, the Board finds that the disability in question is most appropriately evaluated under DC 7806, for dermatitis or eczema, as the diagnostic criteria listed under DC 7806 more closely align to the symptoms manifest by the Veteran's tinea pedis and onychomycosis of the feet. As the Veteran is not rated under diagnostic codes 7800-7805, the Board finds that this amendment will essentially have no impact on his disability rating for tinea pedis and onychomycosis of the feet, as will be discussed in further detail below. Under Diagnostic Code 7806, a 0 percent rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation will be assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed area is affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation will be assigned for dermatitis that covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or with constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118 (2012). Diagnostic Code 7806 remained under the same under the criteria effective October 23, 2008. A VA treatment record from April 2005 reflects the Veteran's complaints of having a foot fungus. The treatment provider indicated that the Veteran had dry skin and onychomycosis. On VA compensation and pension examination in August 2006, the Veteran reported itching, cracking, and blisters on his feet. He remarked that his nails would darken, and he treated them with Kerlac nail gel and Naftin. He also used a pumice stone. The examiner observed dry peeling skin of the left foot and thick and discolored nails. The diagnoses given were moderate tinea pedis of the left foot and mild tinea pedis of the right foot. In a VA examination addendum prepared in October 2006, the examiner specified that onychomycosis and tinea pedis are fungal conditions. She further remarked that the two conditions which the Veteran had were tinea pedis and onychomycosis. On VA compensation and pension examination in June 2009, the Veteran gave a history of fungal infection between his toes and on his heels. He said that he treated his feet and nails with a topical antifungal cream. The examiner observed a scaly rash in the heel area of the Veteran's left foot. It was also noted that a few toenails were affected with a fungal infection. The examiner wrote that the overall skin surface affected was about one percent. The examiner observed that the Veteran's activities of daily living were not affected. In October 2009, another VA examiner recorded the Veteran's complaints of a fungal infection on his feet and toenails. The examiner observed a fungal infection of the Veteran's toenails. At his July 2011 Board hearing, the Veteran stated that he had lost three or four toenails on his left foot. He used a special cream to try to get rid of the fungus. He said that the fungus covered his whole left foot and part of his right foot. In an August 2011 letter, M.V.V., D.P.M., stated that the Veteran was treated for tinea pedis and onychomycosis. He indicated that the Veteran was treated with Naftin cream. On VA compensation and pension examination in February 2012, the examiner observed that several toenails on the right foot were thickened and dystrophic with subungal toenails. There was tenderness upon palpation with scaly plantar skin in a moccasin distribution of the right foot. The Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck. The examiner noted that the Veteran did not have any systemic manifestations due to his skin diseases, and although he used topical medications, he did not use corticosteroids or immunosuppresives for his skin diseases. The report reflects that less than five percent of the Veteran's total body area was affected, and none of his exposed area was affected. The examiner opined that the Veteran's skin conditions did not impact his ability to work. A September 2012 letter from J.S., D.P.M., reflects that the Veteran had chronic athlete's foot. As just noted, the medical evidence of record does not reflect that the Veteran's tinea pedis and onychomycosis covers at least 5 percent of the Veteran's entire body or exposed area during the time period relevant to this appeal. Moreover, the medical evidence of record does not reflect that systemic therapy such as corticosteroids or other immunosuppressive drugs were required at any time during this time period. The Board recognizes that the Veteran treats his skin with topical creams on a daily basis; however, these topical creams are not a corticosteroid or immunosuppressive drug. The Board has considered the Veteran's own reports as to the severity of his skin disorder, and recognizes that he clearly competent to describe the symptoms of a skin rash. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg"). However, the Veteran's statements as to the nature and severity of his skin condition are contradicted by the June 2009 and February 2012 VA examination reports (including the indication that the Veteran's tinea pedis and onychomycosis covered less than 5 percent of his body). The Board finds the objective medical findings of the competent VA examiners to ultimately be more reliable than the vague, subjective descriptions offered by the Veteran. The Board sympathizes with the Veteran's difficulties, but the most probative establishes that his skin disorder does not affect at least 5 percent of either his body or his exposed areas. The Board has reviewed the remaining diagnostic codes relating to skin disabilities but finds that they are inapplicable in this case. See 38 C.F.R. § 4.118 (2012). Specifically, the Board notes that the Veteran has not been noted as having scars due to his tinea pedis and onychomycosis. Therefore, the Board finds the Veteran is most appropriately evaluated under Diagnostic Code 7806, as opposed to any of the criteria or revised criteria for evaluating scars. C. Diabetic Retinopathy The Veteran's claim arises from an October 2006 rating decision which granted service connection and assigned an initial rating for diabetic retinopathy secondary to service-connected diabetes mellitus. The Board notes that during the pendency of the appeal, the applicable rating criteria for eye disabilities, found at 38 C.F.R. §§ 4.75 to 4.84a, were amended effective December 10, 2008. The December 2008 revisions are only applicable to applications for benefits received by VA on or after December 10, 2008. See 73 Fed. Reg. 66,543 -66,554 (November 10, 2008). As the present claim was filed before that date, the changes are not applicable. The overall loss of acuteness or "sharpness" of vision is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. In making this assessment, the best distant vision obtainable after best correction with glasses will serve as the basis of the rating, except in cases of keratoconus, where lenses are medically required. 38 C.F.R. § 4.75. Under 38 C.F.R. § 4.84a, Diagnostic Codes 6061 through 6079 provide a chart wherein the visual acuity in one eye is compared to the visual acuity in the other eye to achieve the bilateral rating. 38 C.F.R. § 4.84a, Codes 6061-6079, Table V (2008). These criteria provide that the impairment of central visual acuity is to be evaluated from noncompensable to 100 percent based upon the degree of the resulting impairment of visual acuity. Id. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a, Table V. A noncompensable disability rating is warranted for impairment of central visual acuity in the following situation: corrected visual acuity in both eyes is 20/40. 38 C.F.R. § 4.84a, Diagnostic Code 6079 (2008). A 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity in one eye is 20/50 and the other eye is 20/40; (2) corrected visual acuity in both eyes is 20/70; (3) corrected visual acuity in one eye is 20/70 and the other eye is 20/40; (4) corrected visual acuity in one eye is 20/100 and the other eye is 20/40. 38 C.F.R. § 4.84a, Diagnostic Code 6079 (2008). A 20 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity in one eye is 20/100 and the other eye is 20/50; (2) corrected visual acuity in one eye is 20/200 in one eye and 20/40 in the other eye; (3) corrected visual acuity in one eye is 15/200 and 20/40 in the other eye. 38 C.F.R. § 4.84a, Diagnostic Code 6077 (2008). A 30 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity in both eyes is 20/70; (2) corrected visual acuity in one eye is 20/100 and the other eye is 20/70; (3) corrected visual acuity in one eye is 20/200 in one eye and 20/50 in the other eye; (4) corrected visual acuity in one eye is 15/200 and 20/50 in the other eye; (5) corrected visual acuity in one eye is 10/200 and 20/40 in the other eye; (6) corrected visual acuity in one eye is 5/200 and 20/40 in the other eye ; or (7) blindness of one eye and corrected vision to 20/40 in the other eye. 38 C.F.R. § 4.84a, Diagnostic Codes 6070, 6074, 6076, 6077, 6078 (2008). A 40 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and 20/70 in the other eye; (2) corrected visual acuity of one eye is to 15/200 and 20/70 in the other eye; (3) corrected visual acuity in one eye is to 10/200 and 20/50 in the other eye; (4) corrected visual acuity is to 5/200 in one eye and 20/50 in the other eye; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/50 and 20/40, respectively, in the other eye. 38 C.F.R. § 4.84a, Diagnostic Codes 6066, 6070, 6073, 6076 (2008). A 50 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity is to 20/100 in both eyes; (2) corrected visual acuity is to 10/200 in one eye and to 20/70 in the other eye; (3) corrected visual acuity is to 5/200 in one eye and 20/70 in the other eye; or (4) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/70 and 20/50, respectively. 38 C.F.R. § 4.84a, Diagnostic Codes 6065, 6069, 6073, 6076, 6078 (2008). A 60 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and the other eye is 20/100; (2) corrected visual acuity of one eye is to 15/200 and the other eye is to 20/100; (3) corrected visual acuity of one eye is to 10/200 and the other eye is to 20/100; (4) corrected visual acuity of one eye is to 5/200 and the other eye is to 20/100; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/100 or 20/70 or 20/100, respectively. 38 C.F.R. § 4.84a, Diagnostic Codes 6065, 6069, 6073, 6076 (2008). A 70 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and the other eye is 20/200; (2) corrected visual acuity of one eye is to 15/200 and the other eye is to 20/200; (3) corrected visual acuity of one eye is to 10/200 and the other eye is to 20/200; (4) corrected visual acuity of one eye is to 5/200 and the other eye is to 20/200; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/200. 38 C.F.R. § 4.84a, Diagnostic Codes 6064, 6068, 6072, 6075 (2008). An 80 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 15/200 and the other eye is 15/100; (2) corrected visual acuity of one eye is to 10/200 and the other eye is to 15/200; (3) corrected visual acuity of one eye is to 5/200 and the other eye is to 15/200; or (4) blindness or anatomical loss of one eye and corrected vision in the other eye to 15/200. 38 C.F.R. § 4.84a, Diagnostic Codes 6064, 6068, 6072, 6075 (2008). A 90 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 10/200 and the other eye is 10/100; (2) corrected visual acuity of one eye is to 5/200 and the other eye is to 10/200; or (3) blindness or anatomical loss of one eye and corrected vision in the other eye to 10/200. 38 C.F.R. § 4.84a, Diagnostic Codes 6064, 6068, 6072, 6075 (2008). A 100 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 5/200 and the other eye is 5/100; (2) blindness or anatomical loss of one eye and corrected vision in the other eye to 5/200; or (3) blindness or anatomical loss of both eyes. 38 C.F.R. § 4.84a, Diagnostic Codes 6061, 6062, 6063, 6067, 6071 (2008). A December 2004 letter from S.B.C., M.D., reflects that the Veteran's corrected visual acuity was 20/200 in the right eye and 20/30 in the left eye. Dr. C. recommended that the Veteran undergo focal laser treatment for diabetic maculopathy in both eyes. In March 2004, Dr. C. recorded corrected visual acuity of 20/400 in the right eye and 20/30 in the left eye. A VA outpatient record from March 2005 reflects that the Veteran had corrected visual acuity of 20/100 in the right eye and 20/40 in the left eye. Slit lamp examination was normal in both eyes. Another VA outpatient record from May 2005 contains corrected visual acuity measurements of 20/200 in the right eye and 20/30 in the left eye. Confrontational visual fields were full to finger counting bilaterally. In September 2005, Dr. C. recorded corrected visual acuity findings of 20/80 in the right eye and 20/20 in the left eye. On VA compensation and pension examination in July 2006, the Veteran reported having laser treatment for his eyes. He also remarked that he used artificial tears. He did not experience diplopia. The examiner indicated that best corrected distance acuities were 20/100 in the right eye and 20/30 in the left eye. Corrected near acuities was 20/160 in the right eye and 20/25 in the left eye. Slit-lamp examination revealed a clear cornea in both eyes, a quiet chamber in both eyes, and no neovascularization of the iris in either eye. An October 2007 letter from Dr. C. reflects that the Veteran's vision was 20/70 in the right eye and 20/20 in the left eye. A May 2008 letter contained the Veteran's report of floaters and an occasional flash in the right eye. His vision was 20/50 in the right eye and 20/20 in the left eye. In July 2008, the Veteran again complained of floaters and flashes, and Dr. C. recorded that the Veteran's vision was 20/60 in the right eye and 20/25 in the left eye. In December 2008, Dr. C. wrote that the Veteran's vision was 20/60 in the right eye and 20/25 in the left eye. Dr. C. indicated in April 2009 that the Veteran's vision was 20/60 in the right eye and 20/30 in the left eye. On VA compensation and pension examination in June 2009, the Veteran reported a history of a shadow in his right eye. He had received four prior laser treatments. He reported photophobia and blurred vision. Uncorrected distance visual acuity was 20/200 in the right eye and 20/100 in the left eye. Best corrected distance visual acuity was 20/70 in the right eye and 20/50 in the left eye. Best corrected near visual acuity was 20/60 in the right eye and 20/40 in the left eye. Extraocular muscle movements were full in both eyes. Confrontation visual fields were full to finger counting in both eyes. An August 2009 letter from Dr. C. reflects that the Veteran's vision was 20/70 in the right eye and 20/30 in the left eye. A VA examination report from November 2009 reflects that the Veteran had blurred vision in both eyes. He reported flashes of light when he moved his eyes. The examiner recorded best corrected distance visual acuity findings of 20/60 in the right eye and 20/50 in the left eye. Best corrected near visual acuity was 20/60 in the right eye and 20/20 in the left eye. Extraocular muscle movements were full in both eyes. Confrontation visual fields were full to finger counting bilaterally. In January 2010, Dr. C. wrote that the Veteran had vision of 20/70 in the right eye and 20/25 in the left eye. In July 2010, his vision was noted to be 20/70 in the right eye and 20/30 in the left eye. A January 2011 letter from Dr. C. contains visual findings of 20/60 in the right eye and 20/30 in the left eye with correction. At his July 2011 Board hearing, the Veteran said that he had vision problems. He said that his vision interfered with his ability to drive. He remarked that his eyeglasses had a strong prescription. He had received multiple laser treatments. On VA compensation and pension examination in February 2012, the Veteran reported a shadow in his right side of vision at times. The examiner recorded uncorrected visual acuity at distance of 20/200 in the right eye and 20/100 in the left eye. Corrected visual acuity at distance was 20/100 for the right eye and 20/50 for the left eye. Corrected visual acuity at near distance was 20/100 for the right eye and 20/40 or better for the left eye. The examiner specified that the Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. Further, the Veteran did not have a corneal irregularity that resulted in severe irregular astigmatism. The examiner wrote that the Veteran did not have diplopia or a visual field defect. Cataracts in both eyes were noted. There was no apakia. The examiner indicated that the Veteran's ability to accomplish tasks requiring depth perception would be impaired, as well as his ability to accomplish tasks that required fine detail at near vision. The Veteran's service connected diabetic retinopathy has been awarded an initial rating 10 percent for diabetic retinopathy prior to February 9, 2012, and 20 percent thereafter. On review of the evidence of record, the Board finds that a rating of 20 percent, but no higher, is warranted throughout the period of appeal. In this regard, the Board notes that in December 2004, the Veteran's corrected visual acuity was 20/200 in the right eye and 20/30 in the left eye, and in May 2005 the Veteran had corrected visual acuity measurements of 20/200 in the right eye and 20/30 in the left eye. Additionally, on VA examination in July 2006, corrected near acuities were 20/160 in the right eye and 20/25 in the left eye. In June 2009, corrected distance visual acuity was 20/70 in the right eye and 20/50 in the left eye. Finally, in February 2012, corrected visual acuity at distance was 20/100 for the right eye and 20/50 for the left eye. The Board acknowledges that other corrected visual acuity findings throughout the period of appeal reflect less impairment than that contemplated by a 20 percent disability rating. However, those lesser findings are interspersed with the findings of increased disability. Extending every reasonable doubt to the Veteran, and viewing the overall level of disability displayed by the service-connected diabetic retinopathy during the entire period of appeal, the Board finds that a single disability rating of 20 percent is warranted. The Board acknowledges that in March 2004, Dr. C. recorded corrected visual acuity of 20/400 in the right eye and 20/30 in the left eye, which would reflect a greater level of severity than that contemplated by a 20 percent rating. However, it appears to be a single, acute finding, as no other visual acuity recordings indicate a level of severity beyond that contemplated by a 20 percent disability rating. As a single, isolated finding, the March 2004 letter from Dr. C. does not represent the sustained increase in symptomatology necessary to sustain the assignment of a staged, higher rating. As none of the other records reflect corrected visual acuity in both eyes of 20/70; corrected visual acuity of one eye is 20/100 and the other eye is 20/70; corrected visual acuity of one eye is 20/200 in one eye and 20/50 in the other eye; corrected visual acuity of one eye is 15/200 and 20/50 in the other eye; corrected visual acuity of one eye is 10/200 and 20/40 in the other eye; corrected visual acuity of one eye is 5/200 and 20/40 in the other eye ; or blindness of one eye and corrected vision to 20/40 in the other eye; a rating in excess of 30 percent is not warranted. Further, the Veteran's cataracts are appropriately considered under the ratings for impairment of vision. In the absence of any concurrent findings of diplopia or other eye abnormalities attributable to the Veteran's diabetic retinopathy, the Board has no grounds to grant a higher evaluation than that already assigned. D. Extraschedular Considerations The Board has considered whether the Veteran is entitled to greater levels of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the tinea pedis, onychomycosis, or diabetic retinopathy disabilities are inadequate. A comparison between the levels of severity and symptomatology of the considered disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. The Board further observes that, even if the available schedular evaluation for each disability is inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that the service-connected disabilities on appeal cause impairment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to an initial compensable disability rating for a skin disability, manifested as tinea pedis and onychomycosis of the feet, is denied. Entitlement to an initial rating of 20 percent, but no higher, for diabetic retinopathy is granted throughout the period of appeal, subject to the regulations governing the award of monetary benefits. REMAND TDIU In a September 2012 statement, the Veteran asserted that his diabetic retinopathy affected his ability to work. In the May 2013 brief located in the Virtual VA file, the Veteran's accredited representative specifically referenced the case of Rice v. Shinseki, 22 Vet. App. 447 (2009) and asserted that the Veteran's September 2012 statement constitutes an informal claim for TDIU as part and parcel with his current claims for increased ratings for his diabetic retinopathy and skin disorder. The Board notes that the Veteran has not filed a formal claim for a TDIU. However, on these facts, the claim for a TDIU is essentially a component of the claims for higher ratings. See Rice, supra. See also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that where a veteran submits evidence of a medical disability; makes a claim for the highest rating possible; and submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a TDIU). The Court has held that a TDIU claim may not be denied without producing evidence, as distinguished from mere conjecture, that the Veteran's disability does not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In Friscia, the Court specifically stated that VA has a duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disability has on the ability to work. Friscia, at 297, citing 38 U.S.C.A. § 5107(a) (West 2002); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a) (2012); Beaty v. Brown, 6 Vet. App. 532, 537 (1994) and Obert v. Brown, 5 Vet. App. 30, 33 (1993). Currently, the evidence is unclear whether the Veteran would be unemployable solely due to his service-connected disabilities. Therefore, on remand the Veteran must be afforded an examination to determine whether his service-connected disabilities affect his employability. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should send to the Veteran and his representative a letter requesting that the Veteran furnish any additional information and/or evidence pertinent to the claim for a TDIU. The RO/AMC's letter should specifically explain how to establish entitlement to a TDIU. The RO should also clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, the RO/AMC should assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, the RO should arrange for the Veteran to undergo examination, by an appropriate health care provider. All appropriate tests and studies should be accomplished, and all findings should be reported in detail. The physician should render an opinion, based upon review of the record and consistent with sound medical principles, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the Veteran's service-connected disabilities, either individually or in concert, render him unable to obtain or retain substantially gainful employment. The physician should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed (typewritten) report. 4. The RO/AMC should also undertake any other development it determines to be warranted. 5. Then, the RO or the AMC should readjudicate the Veteran's claim. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period of time for response. The case should then be returned to the Board for further consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs