Citation Nr: 1322656 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 07-06 262 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES Entitlement to service connection for an eye disorder (other than pterygium/pinguecula, cataracts, or diabetic retinopathy), originally claimed as glaucoma, to include as due to exposure to an herbicide agent and as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from May 1958 to July 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which, in pertinent part, denied claims for service connection for glaucoma, and an increased (compensable) rating for service-connected bilateral pterygium/pinguecula. The Veteran requested a hearing before the Board, but subsequently withdrew this request. In November 2008, the Board remanded the issues of service connection for glaucoma, and an increased rating for service-connected bilateral pterygium/pinguecula to the Appeals Management Center (AMC) for further development. After the AMC completed development and returned the case to the Board for adjudication, in an August 2010 decision the Board remanded the issue of service connection for an eye disorder other than pterygium /pinguecula. In the Board's August 2010 decision, the Board noted that the Veteran had claimed that he had an eye disorder beyond that for which he was already service connected, and that the evidence indicated that he had multiple diagnosed eye disorders; therefore, the Board found that the claim for service connection for glaucoma was to be broadened to include service connection for an eye disorder (other than pterygium/pinguecula) that was originally claimed as glaucoma. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a health disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As neither the April 2009 nor July 2009 VA examiners offered an opinion as to whether any of the Veteran's eye disorders, other than glaucoma, were directly related to service, to include in-service exposure to herbicides, or were caused or aggravated by the Veteran's service-connected diabetes mellitus, the Board remanded the issue of service connection for an eye disorder other than pterygium/pinguecula to the AMC for further development. In compliance with the August 2010 Remand directives, the AMC provided the Veteran with an October 2010 VA eye examination to assist in determining the nature and etiology of the Veteran's claimed eye disorders. After reviewing the October 2010 VA eye examination report, the AMC determined that the VA examiner's opinions regarding the etiologies of the Veteran's respective eye disorders were unclear in some respects, and scheduled the Veteran for an additional VA eye examination for June 2011. The record indicates that the AMC issued a timely June 2011 notice letter to the Veteran regarding the place and date for said examination, but did not state the purpose of the examination. Subsequently, in a June 2011 statement, the Veteran wrote that he no longer wished to pursue a claim for an eye disorder as it had been denied by the Board and that he wanted to have all VA medical examinations regarding that claim cancelled. The Veteran subsequently did not appear for the scheduled June 2011 VA medical examination. As the Veteran did not appear, the October 2010 VA examiner wrote an addendum to the October 2010 VA eye examination report. The AMC then returned the claims file to the Board for adjudication. The Board reviewed both the October 2010 VA eye examination report and the June 2011 addendum, and in a June 2012 decision the Board found that the October 2010 VA examiner did not adequately address the questions of whether the Veteran's eye disorders other than bilateral pterygium/pinguecula were caused or aggravated by the service-connected diabetes mellitus, and did not address the question of whether these disorders were related to any incident of service, to include in-service exposure to herbicides. Accordingly, this matter was again remanded to the AMC for further development to include obtaining another VA eye examination to determine the natures and etiologies of the Veteran's eye disorders other than pterygium/pinguecula. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). Regarding the Veteran's non-appearance at the scheduled June 2011 VA eye examination, the Board reviewed the record and determined that the Veteran's failure to report had been for good cause; namely a credible claim that he has been confused by notices sent to him by the AMC requesting him to appear for a VA examination. 38 C.F.R. § 3.655 (2012). Accordingly, included with its June 2012 remand orders was the Board's order that the Veteran be given the opportunity to appear before a VA examiner. The Veteran's claim was further developed pursuant to the Board's June 2012 remand orders and based on such development the AMC readjudicated the Veteran's claim, denying service connection for four separate eye disorders, but granting service connection for diabetic retinopathy of the right eye and bilateral cataracts. To the extent that service connection for these two disorders has been granted, this represents a full grant of those benefits on appeal. Still remaining on appeal is service connection for all other eye disorders, to the exclusion of those for which service connection has already been granted. The issue before the Board has been changed to reflect this limitation. Additionally, in readjudication this claim post-remand, the AMC split the matter into four separate issues for service connection on a March 2013 Supplemental Statement of the Case. The Board recognizes that the AMC's Supplemental Statement of the Case represents a full and adequate readjudication of the claim; however, the Board has used its discretion to characterize the claim as a single issue, as reflected above, which likewise recognizes the adjudication of the variously diagnosed eye disorders. The Board has reviewed the Virtual VA paperless claims processing system and has considered all relevant documents therein in consideration of the present appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran was exposed to herbicides during service. 3. The Veteran had an in-service injury to the face, including the eyes, which involved a malfunctioning piece of equipment. 4. Other than pterygium/pinguecula, cataracts, and diabetic retinopathy, the Veteran's current eye-related diagnoses are dry eye syndrome, status post-blepharoplasty, pseudoexfoliation of the right eye, and posterior lid margin disease (blepharitis). 5. The Veteran does not have any disorder of one or both eyes which is etiologically related to service, to include related to an in-service face or eye injury and to include exposure to herbicides. 6. The Veteran does not have any disorder of one or both eyes which is etiologically related to a service-connected disability, or that has been permanently worsened by a service-connected disability. CONCLUSION OF LAW An eye disorder (other than pterygium/pinguecula, cataracts, or diabetic retinopathy) was not incurred in service, to include as a result of exposure to herbicides, nor is one proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.313 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO provided a VCAA notice letter to the Veteran in April 2006, prior to the initial adjudication of the service connection claim, and in January 2009. The letters notified the Veteran of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In addition, the notice requirements of the VCAA apply to all elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case in the April 2006 letter, the Veteran was provided with such notice, including the type of evidence necessary to establish a disability rating and effective dates. The Veteran's claim is based, in part, on a theory of secondary service connection. The Statement of the Case issued to the Veteran in December 2006 described the laws and regulations governing secondary service connection. The Veteran, through his representative, has contended secondary service connection in various briefs submitted in support of the claim since October 2008. The Board has included the secondary service connection theory in its November 2008 remand. The January 2009 notice letter provided notice regarding establishing secondary service connection for glaucoma as secondary to the service-connected diabetes mellitus. Based on the foregoing, timely and adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Following the Veteran's receipt of fully-compliant notice, the claim was readjudicated with the issuance of Supplemental Statements of the Case in August 2009, November 2009, February 2012, and March 2013. Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of private and VA treatment. These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issue before the Board. The Veteran indicated that he had no additional information or evidence to submit in support of his claim. The Veteran has been afforded numerous VA examinations, including in May 2006, April 2009, October 2010, and in June 2011. Through the course of these examinations, examiners have conducted physical examinations of the Veteran, reviewed the claims file, taken down and recorded the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on their examinations that have been consistent with the record. Where VA examinations have not fulfilled VA's duty to assist, the Board has ordered additional examination. Having reviewed all VA examinations of record, the Board finds that VA's duty to assist with respect to obtaining VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). All necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claim are also of record. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of this claim have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Legal Criteria for Service Connection 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, 1131; 38 C.F.R. § 3.303(a). Service connection may 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). In this case the Veteran has made a general claim of service connection for one or more disorders of the eyes. The Board's review of the claims file indicates that the Veteran does not have a diagnosis referable to a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2012). This includes any increase in disability (aggravation) that is proximately due to or the result of a service connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by service. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a Veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id. Here, the Veteran has contended that he may have an eye disorder related to his service-connected diabetes mellitus. In order to warrant service connection on a secondary basis, the evidence must show that a claimed eye disorder was caused or aggravated by a service-connected disease or injury, to include diabetes mellitus. Effective October 10, 2006, the section heading of 38 C.F.R. § 3.310 was retitled "Disabilities that are proximately due to, or aggravated by, service-connected disease or injury." Paragraph (b) of 38 C.F.R. § 3.310 was redesignated as paragraph (c), and a new paragraph (b) was added, which describes a requirement for VA to establish a baseline for a disability before adjudicating the question of unnatural progression of that disability due to a service-connected disease or injury. Here, however, the claim on appeal was received in March 2006, and thus the revisions to 38 C.F.R. § 3.310 are not for application in the immediate case. The Board finds that the Veteran is presumed to have been exposed to herbicide. In June 2006 VA received confirmation from the Army that the Veteran had service in Vietnam from June 1968 until June 1969. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a) (2012). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) (2012) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) (2012) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; hairy cell leukemia and other chronic B-cell leukemias; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); Parkinson's disease; and ischemic heart disease. 38 C.F.R. § 3.309(e) (2012). Note 3 at the end of § 3.309 defines ischemic heart disease as not including hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke. Where, however, the evidence does not warrant presumptive service connection, the Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran's claim on appeal relates to one or more disorders of the eyes. Under the provisions 38 C.F.R. § 3.303(c) and 38 C.F.R. § 4.9, refractive errors are considered congenital or development conditions and are not a disease or injury within the meaning of applicable legislation. See Winn v. Brown, 8 Vet. App. 510, 516 (1996). Congenital or developmental conditions, if subjected to a superimposed disease or injury (aggravation), may be service connected for the additional disability. See VAOPGCPREC 82-90. VA must consider whether a refractive error diagnosed during service represented aggravation of a preexisting traumatic eye disability. See Browder v. Brown, 5 Vet. App. 268 (1993); Browder v. Derwinski, 1 Vet. App. 204 (1991). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Reductions or changes in visual acuity are capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the 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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). 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. The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "[i]t 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. Analysis of Service Connection for Eye Disorders The Veteran contends to have injured his eyes during active service. Specifically, he has indicated that during a training exercise in 1963 or 1964 a flame thrower (which he has also described as an incinerator) exploded near his face causing chemical burns to his eyes. The Veteran has also contended that one or more eye disorders may be due to exposure to herbicides during active service. The Veteran does not allege that a claimed injury or disease occurred as a result of combat against enemy forces. The Board finds that the provisions of 38 U.S.C.A. § 1154(b) (West 2002) are not for application based on the Veteran's statements and the evidence of record. Before proceeding, the Board notes that the Veteran is already being compensated for a loss of central visual acuity, encompassed within the criteria for the service-connected pterygium/pinguecula disability. 38 C.F.R. § 4.14 (2012) prohibits the assignment of evaluations for the same symptoms of disability under more than one Diagnostic Code. Accordingly the foregoing adjudication of the Veteran's claim for service connection for an eye disorder other than pterygium/pinguecula, cataracts, or diabetic retinopathy, has been undertaken in such a manner so as to avoid prohibited pyramiding. The Veteran had an in-service injury to the face, including the eyes, which involved a malfunctioning piece of equipment. Service treatment records show that in February 1967 the Veteran was diagnosed with conjunctivitis of the right eye. Examination in November 1971 showed bilateral medial pterygium and conjunctival injection. In June 1975, the Veteran reported that an incinerator had blown up near his face, and service treatment records reflect that cinders were removed from his cornea and conjunctival sac. In October 1975 the Veteran complained of a five day history of growth in the medial aspect of the right eye which felt like sand in the eye. On examination in August 1978 during service, a history of pterygium was indicated, but no current eye disorder was identified. On service retirement examination in May 1979, the Veteran's eyes were normal, although the Veteran endorsed a history of "eye trouble" without further elaboration. Based on the retirement examination, the evidence shows that at service separation the Veteran's eyes were normal. The Board finds that, other than pterygium/pinguecula, cataracts, and diabetic retinopathy, the Veteran's current eye-related diagnoses are dry eye syndrome, status post-blepharoplasty, pseudoexfoliation of the right eye, posterior lid margin disease (blepharitis). "Blepharoplasty" is "plastic surgery of the eyelid." Dorland's Illustrated Medical Dictionary, 228 (31st ed. 2007). "Pseudoexfoliation" is "a condition, often leading to glaucoma, in which deposits on the surface of the lens resemble exfoliation of the lens capsule." Stedman's Medical Dictionary (27th ed. 2000). Posterior lid margin disease, or "blepharitis," is "inflammation of the eye lids." Dorland's, at 228. "Retinopathy" means "retinosis" which is "any of various degenerative, noninflammatory, conditions of the retina." Id. at 1659. "Cataract" is a "partial or complete opacity on or in the lenses of the eye or the capsule of the lenses." Id. at 308. The Board also finds that the weight of the evidence shows that the Veteran does not have any disorder of one or both eyes which is etiologically related to service, to include related to an in-service face or eye injury and to include exposure to herbicides, or that is related to a service-connected disability. After service, the Veteran underwent an eye examination in April 2004 at an Army hospital in Ft. Jackson, South Carolina. There the assessment was of retinopathy, pseudoexfoliation syndrome, and non-surgical cataracts. On VA examination in May 2006, the Veteran stated that during service a flame thrower or incinerator exploded near his face and his eyes had been irritated and red ever since. During the VA examination, the Veteran presented with complaints of irritated and red eyes, as well as decreased, blurred vision. He denied distorted vision, diplopia, visual filed defect, watering eyes and eye swelling. The Veteran used eye drops by prescription and had been for a few years. The Veteran endorsed glaucoma, and Goldman visual field testing was performed, revealing mildly constricted visual fields bilaterally. The diagnoses were cataracts, mild nonproliferative diabetic retinopathy, right eye pseudoexfoliation syndrome and dry eyes. VA treatment records indicate that in July 2006 the Veteran complained of blurry vision. Pupils were equal in size, round, and reactive to light. Visual filed examination was normal. On VA treatment in August 2006, the Veteran denied pain, tearing, redness, burning, or dryness of the eyes, and no glaucoma was found. VA optometry treatment in June 2007 revealed pseudoexfoliative glaucoma of the right eye with good interocular pressure response. Both eyes were dry, and the Veteran endorsed blurry vision. On VA examination in April 2009, the Veteran denied distorted vision, diplopia, and visual filed defect. Following clinical testing and examination, the VA examiner diagnosed diabetes mellitus without background diabetic neuropathy, dry eye syndrome, cataracts, status post blepharoplasty both eyes, myopia without astigmatism, presbyopia, pseudoexfoliation right eye without evidence of glaucoma, and age-related maculopathy both eyes. In a July 2009 addendum, a different VA examiner reviewed the evidence of record and agreed that the Veteran did not have glaucoma to include pseudoexfoliative glaucoma. The examiner noted that the Veteran's cup-to-disc ratio in the right eye only was 0.45, and that although it was "concerning" that there was a somewhat obstructed visual field, this did not correlate with a disease of the optic nerve. Based on the Veteran's pathology, the addendum opinion concluded by opining that, to the extent that the Veteran has visual field impairment, such impairment would be less likely than not due to residuals of any in-service trauma. During the VA examination in October 2010, the Veteran stated that he had experienced diabetes mellitus "for years and years." The Veteran reported having glaucoma for many years and that he had undergone a bilateral blepharoplasty approximately two years prior to the examination. After an eye examination, the VA examiner diagnosed exfoliative glaucoma of the right eye, bilateral cataracts, bilateral dermatochalasis, and bilateral subjective dry eye syndrome. The VA examiner specifically noted that the Veteran did not have diabetic retinopathy. With regard to the etiology of the diagnosed bilateral dry eye syndrome, the VA examiner in October 2010 wrote that the Veteran was 74 years-old at the time of examination and that dry eye syndrome was a common condition seen in the elderly. The examiner noted that dry eye syndrome could be aggravated by the use of the same ophthalmic drops currently used by the Veteran, but also that the Veteran used drops in his right eye only and that the dry eye symptomatology affected both of the Veteran's eyes. Having reviewed the evidence, the VA examiner opined that the Veteran's bilateral dry eye syndrome was at least as likely as not related to the Veteran's history of herbicide exposure or service-connected diabetes mellitus. In offering an opinion about the Veteran's status post bilateral blepharoplasty, the October 2010 VA examiner wrote that the Veteran showed marked bilateral dermatochalasis. The examiner opined that it was at least as likely as not that the Veteran's current dermatochalasis was related to the service-connected diabetes mellitus. With regard to the etiology of the Veteran's s pseudoexfoliation of the right eye, the October 2010 VA examiner wrote that the Veteran had been diagnosed with exfoliative glaucoma of the right eye, and stated that it was at least as likely as not that the Veteran's current exfoliative disorder of the right eye was related to his service-connected diabetes mellitus. The VA examiner went on to state that pseudoexfoliative syndrome was caused by a "protein similar to @@@" [sic] and was deposited on the anterior and posterior segments of the eye, causing an increase in intraocular pressure. The VA examiner indicated that such findings were noted in patients without diabetes mellitus, and, therefore, pseudoexfoliation of the left eye was not a diabetes mellitus-isolated disease. The examiner opined that it was at least as likely as not that the Veteran's current exfoliative disease was related to diabetes mellitus. In a June 2011 addendum to the October 2010 VA eye examination report, the VA examiner repeated the previously arrived-at conclusion that the Veteran's dry eye syndrome was at least as likely as not caused by or the result of the Veteran's diabetes mellitus. Regarding the etiology of the Veteran's status post bilateral blepharoplasty, the VA examiner wrote that the Veteran showed marked bilateral dermatochalasis. The VA examiner opined that it was at least as likely as not that the Veteran's current dermatochalasis was related to the service-connected diabetes mellitus. The June 2011 VA examiner indicated that the Veteran's pseudoexfoliative glaucoma did not have a known cause at this time; however, the VA examiner wrote that some theories showed that this was a systemic disease that manifests in the eye due to different protein synthesis and "also deposits of this material on the intraocular lens which then gets deposited in the angle of the eye," causing the pressure to rise and increasing the likelihood of glaucoma. The VA examiner noted that this was not a condition isolated to diabetes mellitus; therefore, the VA examiner opined that it was at least as likely as not that the Veteran's current exfoliative glaucoma was related to the service-connected diabetes mellitus. On VA examination in June 2012, the Veteran stated that over the prior 10 to 12 years he had been losing vision, especially in the right eye. He also endorsed seeing spots, right eye vision distortion, and watery eyes. The Veteran denied any diplopia or swelling of the eyes. Following examination and diagnostic clinical testing, the examiner's diagnoses included pseudoexfoliative glaucoma with uncontrolled intraocular pressure in the right eye, posterior vitreous detachment of the right eye, status post-blepharoplasty to both upper eye lids, dry eye syndrome. The June 2012 VA examiner opined that the Veteran dry eye syndrome was most likely related to posterior lid margin disease noted on examination, and was not related to diabetes mellitus, and diabetes mellitus did not otherwise affect the Veteran's dry eye syndrome. To that end, the examiner also noted that dry eye syndrome was not at least as likely as not related to any in-service event, including exposure to herbicides. The VA examiner stated that the Veteran had mild bilateral dermatochalasis on examination; however, there was no skin infringing on the visual axis. The examiner opined that dermatochalasis is caused by advanced age and resulting laxity of the skin. The opinion was that neither herbicide exposure nor diabetes mellitus had any causal effect, and diabetes mellitus had no other relationship to dermatochalasis. With regard to a pseudoexfoliation-related disorder to include pseudoexfoliation glaucoma, the VA examiner stated that he was unable to dilate the Veteran's right eye. However, the VA examiner's review of prior eye examinations confirmed clinical findings of pseudoexfoliative material over the right lens capsule. Based on this historical fact, combined with the VA examiner's own finds of uncontrolled intraocular pressure and visual field defect, the VA examiner concluded that the Veteran does have pseudoexfoliation glaucoma of the right eye. The VA examiner opined that this disorder is caused by a genetic mutation in the lysyl-oxidase-like protein 1, also known as LOXL1, and it has been postulated that defects in elastin metabolism may result in the synthesis of pseudoexfoliative material. Based on the foregoing, the examiner opined that the Veteran's pseudoexfoliation-related disorder was not caused by herbicide exposure or diabetes mellitus, and was not otherwise related to diabetes mellitus. In March 2013, an independent medical opinion was provided by a physician who had not previously conducted a VA examination. The physician reviewed the claims file, VA electronic medical records via VA's Compensation and Pension Records Interchange (CAPRI), and the VA examination that had been conducted in June 2012. The physician concurred with the June 2012 VA examiner's opinion that the Veteran's dry eye syndrome was less likely than not incurred in or caused by an in-service event, injury or disease, and was less likely that not related to the Veteran's diabetes mellitus. Citing to an ophthalmological treatise, it was noted that dry eye syndrome can be cause either by deficient tear production or excess evaporation, and the Veteran's posterior lid margin disease results in excess evaporation. It was further noted that posterior lid margin disease is an acquired disorder related to aging. On the matter of the Veteran's status post-blepharoplasty of both eyes, the reviewing physician in March 2013 agreed with the June 2012 VA examiner that the disorder was less likely than not proximately due to, the result of, or aggravated by the Veteran's diabetes mellitus. Rather, the physician pointed to a surgical textbook in describing blepharoplasty as being performed for dermatochalasis and correction of bagginess, fatty protrusions, and lax hanging skin around the eyes. The occurrence of these conditions is age-related. In considering the Veteran's right eye pseudoexfoliative glaucoma, the March 2013 reviewing physician agreed with the conclusion of the June 2012 VA examiner that the disorder was less likely than not incurred in or caused by an in-service event, disease, or injury, to include exposure to herbicide. The reviewing physician also agreed that pseudoexfoliative glaucoma was not due to, the result of, or aggravated by diabetes mellitus. The reviewing physician referenced an ophthalmological treatise in noting that pseudoexfoliative glaucoma is a common form of secondary glaucoma, however, its pathogenesis is obscure and its role in systemic disease is not clear. Regarding the matter of other eye disorders other than those affecting only central visual acuity, the march 2013 reviewing physician agreed with the opinion of the June 2012 VA examiner that the Veteran's bilateral blepharitis eye condition was less likely than not caused by an in-service event, disease, or injury, to include exposure to herbicide. Furthermore, the March 2013 reviewing physician concluded that the Veteran's bilateral blepharitis eye condition was less likely than not due to, the result of, or aggravated by the Veteran's service connected diabetes mellitus. The reviewing physician cited to a medical treatise in opining that the etiology of blepharitis is unknown, but it has been associated with hormone levels, fungal infections, altered immune function, nutritional deficits and neurogenic factors, but not herbicide exposure or diabetes mellitus Based upon a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran does not have any disorder of one or both eyes which is etiologically related to service or a service-connected disorder, or that has been aggravated by a service-connected disability. As the foregoing evidence shows that the Veteran has been diagnosed with dry eye syndrome, status post-blepharoplasty, pseudoexfoliation of the right eye, posterior lid margin disease (blepharitis), and pinguecula. In the case of each of these disorders, medical professionals have determined that none are due to an in-service event, disease, or injury to include exposure to herbicide. Furthermore, the weight of the evidence shows that none are caused by, related to, or aggravated by the service-connected diabetes mellitus. The Board has been presented with competing competent evidence regarding the etiology of some of the Veteran's diagnosed eye disorders, to include the opinions of VA examiner who had etiologically linked one or more eye disorders to the Veteran's service-connected diabetes mellitus. In considering the competent medical opinions above, the Board finds those offered in June 2012 and March 2013 to be especially probative. In particular, the conclusions reached by the June 2012 VA examiner were concurred with on all points following the March 2013 review by an independent physician. Also adding to their probative weight are the numerous medical treatises referenced, with excerpts having been associated with the record. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, generic information from a medical journal or treatise is "general and inconclusive" to establish a medical nexus to a disease or injury. Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). A medical article or treatise can provide support for a claim, but must be combined with an opinion of a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships. Sacks v. West, 316-17. In this case, the provided medical treatise material was not only cited, but also applied to the specific facts of the Veteran's history by a competent medical professional. Additionally, the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Here again, the Board points to the use of medical treatises in combination with, and direct application to, the unique facts of the Veteran's case. Furthermore, the March 2013 reviewing physician not only considered the opinions of previous VA examiners, but included those opinions directly in the submitted report. That these opinions were highly detailed in their discussion of the facts and critical in their analyses, adds even further weight to the value of the opinions reached. See Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record); and see Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits). The Board has fully considered the Veteran's lay statements averring to unremitting eye symptomatology since the in-service explosion of an incinerator or flamethrower. Symptoms such as pain, discomfort, reduction in visual acuity, wet or dry eyes, and changes in the skin around the eye or eyelid are all capable of lay observation; therefore, the Veteran's descriptions of such symptoms are competent. Layno v. Brown, 6 Vet. App. 465 (1994). Nonetheless, for the reasons discussed above, the medical opinions of record are highly probative as compared with the Veteran's lay assertion between current eye disorders and service. The Board finds that the opinions of VA examiners and the medical professional of March 2013, that the Veteran's current eye disorders are not related to service or a service-connected disability, outweigh the Veteran's assertions to the contrary. Having weighed all of the evidence, the Board finds the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. Service connection for an eye disorder, other than pterygium/pinguecula, cataracts, or diabetic retinopathy, is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for an eye disorder, other than pterygium/pinguecula, cataracts, or diabetic retinopathy, is denied ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs