Citation Nr: 1323504 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 08-14 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to service connection for peripheral neuropathy of the right lower extremity, with foot ulcers and Charcot joint disease, to include as secondary to diabetes mellitus, type II. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity, with foot ulcers and Charcot joint disease, to include as secondary to diabetes mellitus, type II. 4. Entitlement to service connection for peripheral neuropathy, right upper extremity, to include as secondary to diabetes mellitus, type II. 5. Entitlement to service connection for peripheral neuropathy, left upper extremity, to include as secondary to diabetes mellitus, type II. 6. Entitlement to service connection for peripheral vascular disease, right lower extremity, to include as secondary to diabetes mellitus, type II. 7. Entitlement to service connection for peripheral vascular disease, left lower extremity, to include as secondary to diabetes mellitus, type II. 8. Entitlement to service connection for diabetic retinopathy. 9. Entitlement to service connection for sleep apnea, to include as secondary to diabetes mellitus, type II. 10. Entitlement to service connection for arthritis of the hips, shoulders, and hands, to include as secondary to diabetes mellitus, type II. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Scott Shoreman, Counsel INTRODUCTION The Veteran had active service from March 1975 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran testified in May 2013 before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing at the above VARO; a transcript is of record. The issue of service connection for diabetic retinopathy 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. The competent and probative evidence establishes that the Veteran's diabetes mellitus, type II, is at least as likely as not related to service. 2. The competent and probative evidence establishes that the Veteran's peripheral neuropathy of the right lower extremity, with foot ulcers and Charcot joint disease, was caused or aggravated by diabetes mellitus, type II. 3. The competent and probative evidence establishes that the Veteran's peripheral neuropathy of the left lower extremity, with foot ulcers and Charcot joint disease, was caused or aggravated by diabetes mellitus, type II. 4. The competent and probative evidence establishes that the Veteran's peripheral neuropathy, right upper extremity was caused or aggravated by diabetes mellitus, type II. 5. The competent and probative evidence establishes that the Veteran's peripheral neuropathy, left upper extremity was caused or aggravated by diabetes mellitus, type II. 6. The competent and probative evidence establishes that the Veteran's peripheral vascular disease, right lower extremity, was caused or aggravated by diabetes mellitus, type II. 7. The competent and probative evidence establishes that the Veteran's peripheral vascular disease, left lower extremity, was caused or aggravated by diabetes mellitus, type II. 8. There is no probative evidence that the Veteran's sleep apnea is causally or etiologically related to service or to the service-connected diabetes mellitus, type II. 9. There is no probative evidence that the Veteran has arthritis of the hips, shoulders, and hands. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type II, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for peripheral neuropathy of the right lower extremity, with foot ulcers and Charcot joint disease, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 3. The criteria for service connection for peripheral neuropathy of the left lower extremity, with foot ulcers and Charcot joint disease, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 4. The criteria for service connection for peripheral neuropathy, right upper extremity, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 5. The criteria for service connection for peripheral neuropathy, left upper extremity, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 6. The criteria for service connection for peripheral vascular disease, right lower extremity, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 7. The criteria for service connection for peripheral vascular disease, left lower extremity, have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 8. The criteria for service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 9. The criteria for service connection for arthritis of the hips, shoulders, and hands have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must advise that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id.; 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to initial adjudication of the Veteran's claims decided herein, letters dated in December 2005 and March 2006 fully satisfied the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the duty to assist in this case, the Veteran's service treatment records, VA treatment records, and private treatment records have been obtained and associated with the claims file. The Veteran was also provided with a VA examination in August 2008 in conjunction with his claim. The examiner provided well-reasoned rationales for the opinions. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran has not made the RO or the Board aware of any additional pertinent evidence that needs to be obtained in order to fairly decide the issues addressed in this decision, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of these issues. As there is no indication that there are additional records that need to be obtained that would assist in the adjudication of the claims, the duty to assist has been fulfilled. The Veteran has been afforded a hearing before a VLJ in 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) (2010) requires that the VLJ 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, during the hearing, the VLJ noted that basis of the prior determinations and noted the elements lacking to substantiate the claims for service connection. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has 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 Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. 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) and that the Board can adjudicate the claims based on the current record. II. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). 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 (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The service treatment records (STRs) show that the Veteran was hospitalized from December 1982 to March 1983. During the course of the hospitalization a glucose tolerance test showed a fasting baseline glucose of 175, a 30 minute glucose load of 244, a 60 minute glucose load of 212, a one and a half hour glucose load of 185, a two hour glucose load of 151, a two and a half hour load of 139, and a three hour load of 163. The STRs do not show other treatment related to glucose or diabetes. Furthermore, the STRs do not show complaints, treatment, or diagnoses related to neuropathy of the lower and upper extremities, with foot ulcers and Charcot joint disease, lower extremity vascular disease, sleep apnea, or arthritis of the hips, shoulders or hands. On an August 1986 medical history report from the Veteran's reserve service, he indicated having never had sugar or albumin in his urine, foot trouble, neuritis, or arthritis, rheumatism, or bursitis. At an October 1986 examination the albumin and sugar were negative in a urinalysis. On an August 1987 medical history report, the Veteran again indicated having never had sugar or albumin in his urine, foot trouble, neuritis, or arthritis, rheumatism, or bursitis. The albumin and sugar were within normal limits on a urinalysis from an August 1987 examination. Private treatment records from September 1994 indicate that the glucose was 425, which was high. In October 1994 it was 150, which was also high. December 2002 VA treatment records state that the Veteran had insulin dependent adult onset diabetes mellitus with neuropathy and that he had recently been diagnosed with obstructive sleep apnea. September 2003 VA treatment records indicate that the Veteran had painless blisters on both feet. The Veteran had also had a large abscess on the right lower leg a month before. Home glucose was in the 200 to 250 range and he was taking insulin. It was noted that the Veteran had severe blistering on both feet. In October 2003 the Veteran underwent debridement due to significant diabetic foot ulcers. VA treatment notes indicate that the Veteran continued to be treated for diabetes with neuropathy and foot ulcerations. In June 2005 a private physician examined the Veteran and diagnosed him with chronic diabetic ulcerations, diabetic neuropathy, and Charcot (neurogenic) arthritis with multiple foot deformities. The arthritic condition was slowly progressing and the Veteran had significant pain with ambulation. X-rays were consistent with neurogenic arthritis with multiple destructive joint disease. July 2005 VA mental health treatment records state that the Veteran had new onset insomnia and that his CPAP machine had recently been adjusted. In September 2005 a VA treating nurse practitioner wrote that the Veteran was followed for chronic medical conditions which included type II diabetes requiring insulin with peripheral vascular disease and peripheral neuropathy. The Veteran was hospitalized in February 2005 for a diabetic foot ulcer. The nurse practitioner felt it was conceivable that the Veteran's in-service exposure to microwave radiation damaged endocrine organs such as the pancreas, contributing to the onset of diabetes and associated difficulties. May 2006 VA podiatry treatment notes indicate that the Veteran had insulin dependent diabetes with neuropathy and Charcot joint disease. A VA treating physician wrote in March 2007 that the Veteran had diabetes that required the use of insulin. The Veteran was told during his service that he was "pre-diabetic" but a further workup was not done. The physician felt that a September 1981 heptic screen showed a slight elevation of serum glutamate pyruvate transaminase (SGPT). It was further noted that it was not clear if the 1994 blood glucose readings were pre- or post-fasting but that regardless they were elevated and had a direct relationship to the current diabetes. It was also conceivable that the Veteran's exposure to electromagnetic radiation during service contributed to his diabetes and complications such as neuropathy and Charcot joints. A private physician who evaluated the Veteran in June 2007 wrote that the Veteran had conditions that included diabetes mellitus, peripheral and autonomic neuropathy, pressure ulcers, dependent edema with stasis dermatitis, Charcot joints in the left foot, and obstructive sleep apnea. The Veteran's in-service exposure to radar emissions and microwave communication antennas may have caused diabetes. In July 2008 the VA treating physician wrote that she treated the Veteran for multiple medical problems, most notably diabetes mellitus, type II. She felt that the March 1983 in-service glucose testing discussed above showed insulin resistance, if not overt diabetes, based on the fasting glucose alone. Therefore, it was her opinion that the diabetes originated at least as far back as 1983. The Veteran had a VA examination in August 2008 at which he reported beginning to take medication for diabetes around 1994. Current symptoms included constant mild aching pains and numbness in his feet, daily severe stabbing pain in the feet, and intermittent pins and needles in the hands. Current treatment included special diet, oral medication and insulin injections. Peripheral neuropathy had been diagnosed in 1997 or 1998, and in addition to pain and constant numbness there had been a diabetic ulcer on the left foot. The examiner also felt that the Veteran had peripheral vascular disease in the lower extremities. On examination there was loss of sensation in the hands and feet and diminished deep tendon reflexes. The examiner felt that peripheral neuropathy was a complication of diabetes. The rationale was the duration of diabetes, that it was poorly controlled, the onset of the complications, and the severity of the complications. As for the diabetes itself, the examiner felt it was less likely as not related to the in-service three hour glucose test from March 1983 because a diagnosis of diabetes requires documentation of two abnormal serum glucose results. It was also noted that the 1983 test was consistent with impaired glucose tolerance, which was not the same as diabetes. The treatment records do not show a diagnosis of diabetes until 1994, which was about 12 years after the impaired glucose tolerance was documented. The VA treating physician wrote in October 2009 that the Veteran clearly had insulin resistance, if not overt diabetes in 1983. The insulin resistance was in the same spectrum of disease process as diabetes, and therefore the physician could not say that the resistance caused the diabetes. The Veteran testified at the May 2013 hearing that there were times during his service when he got faint and his feet burned. He was told during service that he was pre-diabetic and had glucose intolerance and was diagnosed with diabetes in mid-1984. A. Diabetes Mellitus, Peripheral Neuropathy, and Peripheral Vascular Disease The opinions from the August 2008 VA examiner and the VA treating physician are both of probative value. See Nieves-Rodriguez, 22 Vet. App. at 304. When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. § 3.102 (2012). The Board finds that the evidence is at least in equipoise regarding whether the Veteran's diabetes mellitus, type II is related to the insulin resistance that the Veteran exhibited during service in 1983, and that therefore service connection is warranted. The VA examination report and treatment records indicate that the lower and upper extremity peripheral neuropathy and lower extremity vascular disease are complications of the Veteran's diabetes mellitus, type II. Therefore, service connection is warranted. Applying the benefit of the doubt doctrine, all reasonable doubt is resolved in favor of the Veteran when the evidence is in relative equipoise. See 38 C.F.R. § 3.102. Therefore, the Veteran's claims for service connection for diabetes mellitus, type II, peripheral neuropathy of the right and left lower extremities, with foot ulcers and Charcot joint disease, peripheral neuropathy of the upper extremities, and peripheral vascular disease of the lower extremities, are granted. B. Sleep Apnea While the record shows that the Veteran has been diagnosed with sleep apnea, there are no medical opinions of record indicating that it is related to service. The Veteran reported that his VA treating physician said that sleep apnea was related to diabetes. While a layperson can be competent to report a medical diagnosis, the Board does not find the Veteran's testimony credible in this regard because the physician submitted multiple letters regarding the etiology of the diabetes without mentioning sleep apnea. There are no competent opinions of record indicating that the Veteran's sleep apnea is related to service or was caused or aggravated by his diabetes mellitus, type II. Furthermore, the record does not show that the Veteran was diagnosed with sleep apnea until around December 2002. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (to the effect that service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). While the Veteran has made statements to the effect that his sleep apnea is related to his active service or to his diabetes mellitus, type II, he is not competent to make such determinations. His statements on etiology are therefore not afforded probative value. See Jandreau, 492 F.3d at 1376-77; citing Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir.2006)) (though the Federal Circuit held that lay evidence may be competent to establish a diagnosis of a condition, it did not state that lay evidence may be used to determine medical etiology). Because the evidence preponderates against the claim of service connection for sleep apnea, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. C. Arthritis of the Hips, Shoulders, and Hands The record does not show a diagnosis of arthritis of the hips, shoulders, and hands, to include as secondary to diabetes mellitus, type II. The June 2005 statement from private treatment that gave a diagnosis of Charcot (neurogenic) arthritis was referring to the lower extremities. The Veteran is competent to report symptoms such as pain. While there have been symptoms, VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. The VA needs to identify a disability, not symptoms of a disability; although pain that causes limitation of function may result in a disability for VA purposes. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Here, the weight of the evidence demonstrates that the Veteran does not currently have a diagnosis of arthritis of the hips, shoulders, and hands. The Court has indicated that, in the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is also no basis on which to find that arthritis of the hips, shoulders, and hands has been present at any point during the claim or appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The treatment records also show no diagnosis of arthritis of the hips, shoulders, and hands. Since an element for establishing service connection on a direct basis or a presumptive basis is the Veteran being diagnosed with arthritis of the hips, shoulders, and hands at any time during the pendency of his appeal and this claimant does not have this or a related diagnoses, the Board finds that entitlement to service connection for this disability must be denied. 38 C.F.R. §§ 3.303, 3.307, 3.309. ORDER Service connection for diabetes mellitus, type II, is granted. Service connection for peripheral neuropathy of the right lower extremity, with foot ulcers and Charcot joint disease, is granted. Service connection for peripheral neuropathy of the left lower extremity, with foot ulcers and Charcot joint disease, is granted. Service connection for peripheral neuropathy, right upper extremity, is granted. Service connection for peripheral neuropathy, left upper extremity, is granted. Service connection for peripheral vascular disease, right upper extremity, is granted. Service connection for peripheral vascular disease, left upper extremity, is granted. Service connection for sleep apnea is denied. Service connection for arthritis of the hips, shoulders and hands is denied. REMAND The August 2008 VA examiner noted that a February 2008 optometry examination showed no evidence of retinopathy. However, the examination report states that the Veteran had the diabetic related visual symptom of intermittent blurred vision. The examination report did not explain the apparent contradiction between stating that the Veteran does not have diabetic retinopathy but noting that his vision was affected by diabetes. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, the Veteran must be scheduled for a new VA examination for diabetic retinopathy. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination of his eyes. The claims file should be made available to the examiner for review prior to the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. Based on the examination and review of the record, the examiner is requested to provide an opinion as to whether any symptoms related to the Veteran's vision are due to or are otherwise caused by or aggravated by the service-connected diabetes mellitus, type II. The nature of any impairment the symptoms impose should be identified, including any formal diagnosis, as the case may be. A detailed rationale for any opinion expressed should be set forth. If the examiner cannot reach an opinion without resorting to speculation, the examination report must state why that is so. 2. Readjudicate the Veteran's claim. If the benefit sought on appeal is not granted in full, the RO should issue the Veteran and his representative a supplemental statement of the case and provide him an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs