Citation Nr: 1319816 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 07-34 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for an eye disability, to include as secondary to service-connected type II diabetes mellitus. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to July 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran contends that he is entitled to service connection for an eye disability to include as secondary to service-connected type II diabetes mellitus. The Board remanded this matter in February 2013 for a VA opinion clarifying past findings. Although an opinion was offered in March 2013, the Board finds that it is not in compliance with the February 2013 remand. Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the Board indicated that the examiner was to explain the discrepancy regarding the presence or absence of diabetic retinopathy as seen in the October 2006 VA treatment records and the January 2007, February 2007, and June 2010 VA examination reports. The examiner was to also explain the significance of the teleretinal imaging findings in October 2006 which indicate moderate nonproliferative diabetic retinopathy. Further the examiner was to provide an opinion as to whether any currently diagnosed eye disability is proximately due to or aggravated by the Veteran's service-connected type II diabetes mellitus. The examiner was to specifically address the study identified by the Veteran which indicates a relationship between dry eye syndrome and type II diabetes mellitus. The March 2013 clinician indicated that there was no February 2007 VA examination in the electronic file; however the claims file contains a February 5, 2007 VA diabetes mellitus examination report which addresses visual symptoms of the Veteran. Additionally the clinician did not offer an opinion as to whether any currently diagnosed eye disorder is due to or aggravated by the service-connected diabetes mellitus. The Veteran has been diagnosed with cataracts, and with presbyopia as well as dry eye syndrome. Since the examiner did not review the February 2007 VA examination report when the examiner addressed the discrepancy of the October 2006 abnormal teleretinal imaging findings with the noted VA examination findings, the Board finds that a remand is warranted for an addendum opinion which includes review of all of the pertinent evidence. An opinion or examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Further the clinician did not offer the nexus opinion as mandated by the Board in its February 2013 Remand. Thus an addendum opinion is required. Stegall v. West, 11 Vet. App. 268 (1998). The record shows that a February 2013 letter sent to the Veteran to allow him the opportunity to identify and submit information regarding any medical treatment he may have received for his eye disorder was returned to VA for postage. Thus while the case is in remand status, another letter should be sent to the Veteran. Accordingly, the case is REMANDED for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of the issue currently on appeal. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must obtain all relevant VA medical records not currently of record. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) explain that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. After the above development is completed, the claims file must be returned to the examiner who offered the March 2013 opinion, if available. If the March 2013 examiner is not available to provide the addendum, another qualified examiner must be asked to review the claims file and provide the requested opinions. The claims file and all pertinent records on Virtual VA must be made available to the examiner, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Following a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must explain the discrepancy regarding the presence or absence of diabetic retinopathy as seen in the October 2006 VA treatment records and the noted VA examination reports to include the February 2007 VA examination report in the file. Additionally, the examiner must provide an opinion as to whether any currently diagnosed eye disability is proximately due to or aggravated by the Veteran's service-connected type II diabetes mellitus. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. After the requested medical opinion has been completed, the RO must review the medical report to ensure that it is in complete compliance with the directives of this remand. The medical report must be returned to the examiner if it is deficient in any manner and the RO must implement corrective procedures at once. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be readjudicated. If the issue on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran 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). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).