Citation Nr: 1324239 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 04-22 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for dermatochalasis and blepharoptosis (blepharochalasis) of the upper eyelids. 2. Entitlement to service connection for blepharitis of the eyelids. 3. Entitlement to service connection for glaucoma. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD E. Joyner, Counsel INTRODUCTION The Veteran retired in April 1999, with more than 24 years of active duty service. These matters come before the Board of Veterans' Appeals (Board) from a January 2004 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) located in Waco, Texas. The issues on appeal were previously before the Board in June 2006, March 2010, and June 2012, and were on each occasion remanded for the purpose of affording the Veteran a VA examination with a medical opinion that was to address the medical matters presented by this appeal. The issue of entitlement to service connection for blepharitis of the eyelids 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. There has been no demonstration by the competent medical, or competent and credible lay, evidence of record that the Veteran had glaucoma during service or that his current glaucoma is related to active service. 2. There has been no demonstration by the competent medical, or competent and credible lay, evidence of record that the Veteran had dermatochalasis and/or blepharoptosis (blepharochalasis) during service or that his current dermatochalasis and/or blepharoptosis (blepharochalasis) is related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for glaucoma have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection for dermatochalasis and/or blepharoptosis (blepharochalasis) have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Duty to Notify 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. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, it will assist in substantiating or that is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In VA correspondence to the Veteran in August 2003 and July 2006, VA informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The July 2006 notice also informed the Veteran as to the law pertaining to the assignment of a disability rating and effective date as the Court required in Dingess/Hartman. In Pelegrini, the Court held that compliance with 38 U.S.C.A. § 5103 required that VCAA notice be provided prior to an initial unfavorable AOJ decision. Because VCAA notice in this case was not completed prior to the initial AOJ adjudication denying the claim, the timing of the notice does not comply with the express requirements of the law as found by the Court in Pelegrini. In this regard, although the July 2006 letter, which contained the notice regarding disability ratings and effective dates, was sent after the initial unfavorable decision by the Agency of Original Jurisdiction (AOJ) in January 2004, following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the claim in both a July 2008 and March 2013 supplemental statement of the case. As such, there was not prejudice to the Veteran concerning the timing of these notice elements. See Prickett v. Nicholson, 20 Vet. App. 370 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect). Duty to assist With regard to the duty to assist, the claim's file contains the Veteran's service treatment records, VA medical records, VA examinations and medical opinions, and the Veteran's statements in support of his claim. The Board has carefully reviewed the Veteran's statements and concludes that there has been no identification of further available evidence not already of record. The Board has also 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 claims for which VA has a further duty to obtain. The Veteran was afforded VA examinations in September 2003, April 2007, May 2008, March 2010, December 2011, and August 2012, and medical opinions in July 2011, November 2012, and March 2013 with respect to his claims decided herein. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the March 2013 medical opinion report is adequate. The examiner reviewed the claims file, considered the pertinent evidence of record, to include the Veteran's service treatment records, and the examiner provided an adequate rationale for the opinion proffered. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its June 2006, March 2010, and June 2012 remands. The June 2006 remand instructed the RO to contact the Veteran and request that he furnish the names, addresses and dates of treatment of all medical providers from whom he has received treatment for his eye disabilities, and to obtain all identified records. Additionally, all remands essentially instructed the RO to afford the Veteran a VA eye examination in order to determine the nature and etiology of all eye disabilities, and to provide an adequate rationale for any opinion given. The RO sent the Veteran a letter in July 2006 which complies with the directive in the June 2006 remand. Moreover, a medical opinion was obtained in March 2013 regarding the issues decided herein. The Board finds that the RO has complied with the Board's instructions and that the March 2013 medical opinion report substantially complies with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Factual Background Service treatment records dated in September 1992 and October 1992 reflect suspicious optic nerve cupping bilaterally and that glaucoma was suspected. A March 1993 service treatment record notes that the Veteran's had large deep cups but normal intraocular pressure. A November 1993 service treatment record notes that the Veteran had borderline high normal intraocular pressure. A March 1994 service treatment record notes significant cupping, normal intraocular pressure, and that the Veteran was at high risk for primary open angle glaucoma. An April 1994 service treatment record notes that there was significant retinal cupping. Prophylactic drops were to be continued until scheduled full flight physical a week later. A July 1995 service treatment record notes that the Veteran had been on glaucoma treatment for the past year and that a diagnosis of glaucoma suspect was made. A September 1995 service treatment record notes an assessment of deep cupping of optic discs with normal intraocular pressures. It was noted that the Veteran did not wish to continue the drops given the option and the provider stated that it was safe to discontinue the drops. A November 1996 service treatment record notes an impression of physiologic cupping, not glaucomatous. The Veteran was recommended fit for full duty, including aviation annual examination. A December 1998 service treatment record notes an assessment of large physiological cupping with normal intraocular pressure. The health care provider stated that there was no apparent change over the last eight to ten years. Yearly ophthalmology examinations were recommended. A September 2003 VA examination report notes that the Veteran was referred for evaluation of bilateral blepharoptosis and glaucoma. The Veteran indicated that he was told he possibly had glaucoma when he was on active duty. He indicated that he was temporarily treated with a topical medication but later this treatment was discontinued. On external examination of the eyes, there was dermatochalasis of the upper eyelids, bilaterally. There were palpebral fissures 11 millimeters in both eyes in primary gaze. Slit lamp was normal bilaterally except that there was mild nuclear sclerosis of both eyes in the lens. Intraocular tensions were 16 mm Hg in both eyes. Dilated fundus examination was normal except disk examination. Disk examination was abnormal in both eyes, with enlarged optic nerve cups bilaterally. The cup to disk ratio of 0.8 in the right eye and 0.75 in the left eye. Goldmann visual field test revealed mild, nonspecific generalized suppression in both eyes. No glaucomatous defects were identified. The impression was optic nerve cupping in both eyes, and dermatochalasis of both upper eyelids. The examiner opined that the exact etiology of optic nerve cupping in this case is unknown and the condition may have a developmental/physiologic origin. The intraocular tensions were normal on the current examination, and there were no glaucomatous visual field defects identified. However, the examiner stated that the diagnosis of glaucoma cannot be completely ruled out and long-term follow-up is indicated. The examiner noted that, by reported history, optic nerve cupping was apparently diagnosed while the Veteran was on active duty. On current examination there was bilateral dermatochalasis of the upper eyelids. The examiner was unable to determine whether or not this condition was documented during active duty. The examiner felt that there may be very mild superior visual field suppression in both eyes, which may be due to dermatochalasis, but otherwise this condition has no visual significance at this point. An April 2007 VA examination report reflects a diagnosis of glaucoma suspect. External examination of the eyes was normal. Slit lamp examination revealed that anterior chambers were deep. The examiner opined that the Veteran does not have any eye disease related to military service. The examiner further stated that the Veteran may possibly be developing glaucoma. He was advised to obtain a routine appointment through his primary care physician for further evaluation in the eye clinic. A May 2008 VA examination report notes that external examination of the eyes was normal. Slit lamp examination revealed that the anterior chambers were deep. The cup to disk ratio on the right eye was 0.75 and on the left eye was 0.65. The disks, maculae, and vessels were otherwise within normal limits. The diagnosis was primary open-angle glaucoma. The examiner stated that although this patient has normal visual fields, his pressure is elevated and the appearance of his optic nerves would strongly suggest the presence of primary open-angle glaucoma. The diagnosis was primary open angle glaucoma. A Goldmann Visual Field was within normal limits. A March 2010 VA examination report indicates that external eye examination was normal. The cup/disk ratio on the right was 0.9 and 0.8 on the left. The reminder of the disks, maculae, and vessels were within normal limits. The diagnosis was primary open angle glaucoma. A June 2011 VA eye ophthalmology note indicates that the Veteran has dermatochalasis bilaterally and primary open angle glaucoma. A July 2011 VA medical opinion addendum report states that the claims file was reviewed. The examiner opined that the dermatochalasis, blepharoptosis, blepharitis, and glaucoma are not related to military service. A December 2011 VA examination report notes that the Veteran has dermatochalasis of the upper lids and primary open angle glaucoma. The examiner explained that dermatochalasis is a skin redundancy and loss of elasticity, is a result of aging, and is very common. The examiner opined that it is not related to military service and is a normal process of aging. The examiner also noted that the Veteran does not have evidence of blepharitis of the eyelids at this time. An August 2012 VA examination report notes a diagnosis of glaucoma, open angle. The examiner also noted that the Veteran has blepharochalasis, not related to military service. The examiner further stated that there is no evidence of blepharitis. A November 2012 VA medical opinion addendum report notes that the claims file was reviewed in its entirety and there was no change in opinion or records to suggest any etiological relationship to service. A March 2013 independent medical opinion report notes that the Veteran's records were reviewed. The examiner recounted the Veteran's active service treatment records showing deep physiologic cupping, no clinical signs of glaucoma, borderline high normal pressure of eyes attributed to large deep cupping, and suspected glaucoma. The examiner opined that the Veteran's glaucoma is less likely as not incurred, caused by, or proximately due to his military service. The examiner noted that the December 1998 clinical note indicated that the Glaucoma Hemifield test was within normal limits. Although the October 1992 note stated that glaucoma was suspect, the December 1998 note clearly and unmistakably finds that large physiologic cuppings were without near or distance intraocular pressure abnormalities. The examiner stated that the Veteran was diagnosed with glaucoma in October 2009. He separated from service in 1999, and there is a 10 year gap between the diagnosis of glaucoma and service. The examiner explained that although the diagnosis of glaucoma uses the cup to disc ratio for diagnostic purposes, cupping by itself is not necessarily indicative of glaucoma. However, experts agree than an increase in cupping, with aging, can be associated with the development of glaucoma. Second, glaucoma is defined as a multifactorial optic neuropathy with a characteristic acquired loss of optic nerve fibers. The definitive characteristics of glaucoma are based on visual field loss or the appearance of the disc or retinal nerve fiber layer. Early or mild glaucoma is characterized by optic nerve abnormalities with normal visual fields. Moderate glaucoma is defined as visual field abnormalities in one hemifield, not within five degrees of fixation, whereas severe glaucoma involves visual field abnormalities in both hemifields or loss within five degrees of fixation. As the Veteran's history details, his physiologic deep cuppings were stable with his youth. However, aging became an added risk factor for his development of glaucoma in 2009. As such, it is less likely as not that the Veteran's glaucoma was incurred in service or was caused by service. The examiner opined that it is at least as likely as not that the development of glaucoma was due to the normal aging process and the physiologic deep cupping that was hereditary in nature. Furthermore, the examiner stated that the military took great care of the Veteran's eye conditions throughout his military career to be sure that these conditions were not progressive. The March 2013 independent medical opinion report also notes that it is less likely as not that the Veteran's blepharochalasis (blepharoptosis) and/or dermatochalasis was/were incurred in, caused by, or proximately due to his time in service. The examiner stated that by definition, blepharochalasis (which the examiner stated is also known as blepharoptosis) is an inflammation of the eyelid with eyelid swelling and dermatochalasis is an overhanging of the eyelids. The examiner stated that although the August 2012 VA examination diagnosed blepharochalasis, there was no clinical evidence in the active duty records of a diagnosis of, or treatment for this condition. Furthermore, the current literature does not present a nexus of blepharochalasis and/or dermatochalasis with physiologic deep cupping or glaucoma. Therefore, the examiner opined that these two diagnoses are independent and mutually exclusive of each other. In conclusion, the examiner found that there was no medically based clinical evidence to support the Veteran's claimed blepharochalasis and/or dermatochalasis, bilaterally, being incurred in service. The examiner found that it is at least as likely as not that the inflammation, overhanging and swelling of the eyelids were part of the normal aging process. Legal criteria and Analysis With respect to the Veteran's claims, the Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, or applicable presumptive period, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). However, in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As discussed more thoroughly below, the Veteran is not diagnosed with an eye disability which is recognized as a chronic disability in 38 C.F.R. § 3.309(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, will be presumed to have been incurred in service if manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim for disability benefits. In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Dermatochalasis and Blepharoptosis of the Upper Eyelids The Veteran has claimed entitlement to service connection for dermatochalasis and blepharoptosis (blepharochalasis) of the upper eyelids. In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for dermatochalasis and blepharoptosis (blepharochalasis) of the upper eyelids. The Board notes that the service treatment records do not show any evidence of treatment for or diagnosis of dermatochalasis, blepharoptosis (blepharochalasis) of the upper eyelids, or any other disability of the upper eyelids. Moreover, the post-service treatment records are negative for relevant complaints, symptoms, findings or diagnoses of such for approximately four years after the Veteran's separation from active duty. The Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Notably, the September 2003 VA examination report reflects a diagnosis of dermatochalasis, a June 2011 VA treatment reflects a diagnosis of dermatochalasis, and an August 2012 VA examination report reflects a diagnosis of blepharochalasis (blepharoptosis). However, neither the VA examination reports nor the VA treatment record links the Veteran's post-service diagnosis to his active service. Moreover, the only competent medical opinion of record, the March 2013 independent medical opinion report, is against the claim. Notably, the March 2013 medical opinion report, which reflects that the entire claims file was reviewed, and in fact, recounts the pertinent eye examinations in service, states that it is less likely as not that the Veteran's blepharochalasis (blepharoptosis) and/or dermatochalasis was incurred in, caused by, or proximately due to his time in service. The examiner stated that although the post-service medical evidence includes a diagnosis of blepharochalasis, there was no clinical evidence in the active duty records or a diagnosis of, treatment for this condition. Furthermore, the current literature does not reflect that there is any nexus between blepharochalasis (blepharoptosis)/dermatochalasis and physiologic deep cupping (which was found during service) or glaucoma. Therefore, the examiner opined that the diagnoses of blepharochalasis/dermatochalasis and physiologic deep cupping/glaucoma are independent and mutually exclusive of each other. In conclusion, the examiner found that there was no medically based clinical evidence to support the claim that the Veteran's blepharochalasis (blepharoptosis) and/or dermatochalasis, bilaterally, was incurred in service. Instead, the examiner found that it is at least as likely as not that the inflammation, overhanging and swelling of the eyelids (ie., the diagnoses of blepharoptosis/blepharochalasis and dermatochalasis) were part of the normal aging process. As previously noted, the Board is aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence. Further, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to observe his eyelid symptoms during or after service. The Board finds him to be credible in this regard. However, he has not been shown to have had the requisite medical training to render him competent to diagnose the complex eye and eyelid disabilities at issue. He has not alleged that he suffered from any eyelid symptoms such as drooping, overhanging, or swelling during service or continuously since then. Despite the extensive eye examinations throughout the Veteran's service and post-service treatment records, the first time he was found to have any problems with his eyelids is in September 2003, when dermatochalasis was diagnosed. Moreover, the objective medical evidence of record generally relates the Veteran's diagnoses of blepharoptosis (blepharochalasis) and dermatochalasis to his natural aging process. As such, the Board finds that the Veteran's assertions, as minimal as they are, are outweighed by the objective medical evidence of record. In sum, the evidence demonstrates that the Veteran is not entitled to service connection for blepharoptosis (blepharochalasis) and dermatochalasis. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Glaucoma The Veteran contends that he is entitled to service connection for glaucoma. A review of the service treatment records shows that the Veteran had borderline high normal intraocular pressure in November 1993, he consistently had large or deep bilateral cupping during service, and glaucoma was suspected in September 1992, October 1992, and July 1995. However, in November 1996, it was determined that although he deep physiologic cupping, he did not have glaucoma. Finally, a December 1998 service treatment record notes an assessment of large physiological cupping with normal intraocular pressure, and that there was no apparent change over the last eight to ten years. Although glaucoma was suspected previously, post-service treatment records show that it was not actually diagnosed until May 2008, close to 10 years following active service. Moreover, the only competent medical opinion of record is against the claim. Notably, the March 2013 independent medical opinion report reflects that, after reviewing the claims file, the Veteran's glaucoma is less likely as not incurred in, caused by, or proximately due to his military service. The examiner recounted the service treatment records, including the December 1998 clinical note indicating that the Glaucoma Hemifield test was within normal limits, and stated that although the October 1992 service treatment note stated that glaucoma was suspect, the December 1998 note clearly and unmistakably finds that large physiologic cuppings were without near or distance intraocular pressure abnormalities. The examiner pointed out that there was a period of approximately 10 years between active service and the first diagnosis of glaucoma. The examiner explained that although the diagnosis of glaucoma uses the cup to disc ratio for diagnostic purposes, cupping by itself is not necessarily indicative of glaucoma. However, experts agree than an increase in cupping, with aging, can be associated with the development of glaucoma. Second, glaucoma is defined as a multifactorial optic neuropathy with a characteristic acquired loss of optic nerve fibers. The definitive characteristics of glaucoma are based on visual field loss or the appearance of the disc or retinal nerve fiber layer. Early or mild glaucoma is characterized by optic nerve abnormalities with normal visual fields. Moderate glaucoma is defined as visual field abnormalities in one hemifield, not within five degrees of fixation, whereas severe glaucoma involves visual field abnormalities in both hemifields or loss within five degrees of fixation. The examiner further explained that the Veteran's service treatment records show that his physiologic deep cuppings were stable with his youth. However, as aging became an added risk factor, he later developed glaucoma in 2009. As such, the examiner concluded that it is less likely as not that the Veteran's glaucoma was incurred in service or was caused by service. Instead, the examiner opined that it is at least as likely as not that the development of glaucoma was due to the normal aging process and the physiologic deep cupping that was hereditary in nature. Furthermore, the examiner stated that the military took great care of the Veteran's eye conditions throughout his military career to be sure that these conditions were not progressive. The Veteran is competent to provide lay evidence concerning symptoms after service. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ('although interest may affect the credibility of testimony, it does not affect competency to testify'). Therefore, although the Veteran is competent to report ongoing symptoms since service, glaucoma was not actually found during service or until approximately 10 years later, and the Veteran has not been shown to have the requisite medical training to render a diagnosis of glaucoma or relate the etiology of such diagnosis to active service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, Note 4 (Fed. Cir. 2007) (holding that sometimes a layperson will be competent to identify a medical condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer, and remanding to the Court to remand to the Board to decide whether lay evidence was competent and sufficient to establish a shoulder dislocation); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses and cautioning that lay testimony that veteran suffered a particular illness, bronchial asthma, was not competent because matter required medical expertise); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (noting that veteran's statements were competent to describe the observable flatness of his feet); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify to ringing in the ears (tinnitus) which is capable of lay observation); Barr v. Nicholson, 21 Vet App 303, 308-09 (2007) (holding that lay testimony is competent to establish the presence of varicose veins). In this case, although the Veteran is competent to report that he experienced eye pressure since service, he has not actually alleged such ongoing symptomatology. In any event, he is not competent to state that this symptomatology is glaucoma, as that is a determination to be made through specialized testing performed by someone with medical expertise. Thus, the Board cannot assign any significant weight to the Veteran's lay assertions about the timing of his glaucoma diagnosis or etiology of his currently diagnosed glaucoma. In sum, although there was evidence of some borderline high intraocular pressure, suspected glaucoma, and physiologic deep cupping in service, glaucoma was not actually diagnosed in service or until approximately 10 years later. Moreover, the only competent medical opinion of record, the March 2013 medical opinion report, states that deep cupping is not the only diagnostic measure used in order to diagnose glaucoma. Based upon a thorough review of the evidence of record, the March 2013 examiner opined that it is at least as likely as not that the Veteran's current glaucoma is related to the natural aging process, and it is less likely than not that it is related to active service. The Board finds that the March 2013 examiner provided an adequate rationale for the stated opinion. There is no opinion in favor of the claim. Therefore, the evidence demonstrates that the Veteran is not entitled to service connection for glaucoma. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Entitlement to service connection for dermatochalasis and blepharoptosis (blepharochalasis) of the upper eyelids is denied. Entitlement to service connection for glaucoma is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In the June 2012 remand, the Board indicated that the July 2011 VA medical opinion addendum report states that blepharitis is not related to military service; however, no rationale was provided. In contrast, the December 2011 VA examiner (the same examiner who provided the July 2011 addendum opinion) found no evidence of blepharitis. The Board further indicated in the June 2012 remand that although no diagnosis of blepharitis was shown in December 2011, the examiner still failed to provide a nexus opinion addressing the likelihood that any active blepharitis, occurring at any time during the period of the claim, was associated with service, as the requirement of the existence of a current disability for service connection claims is satisfied when a claimant has the disability at the time he files his claim or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Unfortunately, there is still no medical opinion regarding whether any active blepharitis occurring at any time during the period of the claim is etiologically related to service. Notably, the August 2012 VA examination report (conducted by the same examiner who provided the July 2011 addendum and the December 2011 VA examination) again only notes that blepharitis was not found on examination and the March 2013 medical opinion report does not address blepharitis whatsoever. Therefore, a remand is again required in order to obtain such an opinion. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the August 2012 VA examiner or the clinician who provided the March 2013 medical opinion report, or suitable substitute, in order to obtain a medical opinion as to whether it is at least as likely as not (50 percent or better probability) that blepharitis demeonstrated at any time during the appeal is related to the Veteran's active service. The examiner is instructed to ignore the lack of a current diagnosis of blepharitis, and focus solely on the prior July 2011 implied diagnosis of blepharitis. The VA examiner is requested to provide a thorough rationale for the opinion(s) provided. The VA examiner should review the claims file and this fact should be noted in the accompanying medical report. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. If the VA examiner is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided, and identify what additional development, if any, would facilitate rendering such an opinion. 2. The RO/AMC should ensure that the requested action has been accomplished (to the extent possible) in compliance with this Remand. If the ordered action is determined to have not been undertaken or to have been taken in a deficient manner, appropriate corrective action must be taken. See Stegall v. West, 11 Vet. App. 268 (1998). 3. Once the above actions have been completed, the RO must re-adjudicate the Veteran's claim. If the benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs