Citation Nr: 1328031 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 12-26 915 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for glaucoma. ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1957 to August 1959. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision of Houston, Texas Department of Veterans Affairs (VA) Regional Office (RO). 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). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. REMAND The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claim. While the notice provisions of the VCAA appear to be satisfied the Board finds that further development of the record is necessary to comply with VA's duty to assist the Veteran in the development of facts pertinent to the claims. See 38 C.F.R. § 3.159. The Veteran seeks service connection for glaucoma, and asserts that glaucoma was present during his active duty service (albeit undiagnosed due to inadequate examinations therein). Service treatment records (STRs) are silent as to any complaint, treatment, or diagnosis of glaucoma. However, the STRs contain a February 1958 Optometry Department re-evaluation, indicating the Veteran was seen for his vision in service. His service entrance and separation examination reports reflect he wore glasses to correct defective vision. The record shows that postservice the Veteran has received treatment for glaucoma, since 1991 (and had eye surgeries). He has specifically identified treatment by Dr. J. Zetrvas, who diagnosed glaucoma, and indicated that records of such treatment were on file at Braverman, Terry, Oui Ophthalmology Center. Records of eye examinations from 1997 to 2012 from Braverman, Terry, Oui Ophthalmology Center were obtained; however, there is no report of evaluation or treatment by Dr. Zetrvas (and the record does not include the records of the Veteran's eye surgeries). These records are pertinent outstanding evidence- that must be secured. Additionally, in a June 2012 statement, Dr. T. Wiginton, MD stated that the Veteran has had glaucoma since the time of his military service; she does not identify the factual data that support such conclusion (i. e., whether it is based on records she reviewed, or on the Veteran's reported history). The Board notes the Veteran has not been afforded an examination with respect to this claim. VA must provide an examination to secure a medical nexus opinion when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifested during an applicable presumptive period for which he qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with his service or a service-connected disability; but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In McLendon, the Court noted that the third prong of the assessment as to whether an examination is needed is a low threshold requirement. Here, the Veteran has glaucoma; a private physician states the glaucoma began in service; and the Veteran asserts his glaucoma was present (but undiagnosed) in service. The low threshold standard endorsed in McLendon is met; an examination to secure a medical opinion is necessary. Accordingly, the case is REMANDED for the following: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should ask the Veteran to identify any (and all) private providers of treatment and/or evaluation he has received for glaucoma since service (specifically indicating whether he received any, prior to 1991) and to provide the authorizations necessary for VA to obtain outstanding records of all such private evaluations and treatment, to specifically include Dr. T. Wiginton and Braverman, Terry and Oui Ophthalmology. The RO should secure for the record copies of the complete clinical records of all evaluations and treatment from the sources identified, (to specifically include the complete treatment records of Dr. T. Wiginton and the complete treatment records from Braverman, Terry and Oui Ophthalmology). If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to the RO's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. The RO should also ask the Veteran to obtain for the record from Dr. T Wiginton explanation of the basis for her conclusion that he has had glaucoma since service (i.e., if it is based on any records showing findings of glaucoma prior to 1991- and if so to identify such records).. 2. Thereafter, the RO should arrange for an ophthalmologic examination of the Veteran to determine the etiology of his glaucoma. The entire record must be reviewed by the examiner in conjunction with the examination. Based on examination of the Veteran and review of his claims file, the examiner should provide an opinion that responds to the following: Based on the factual data in the record, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's glaucoma began in (or is otherwise related to) his military service? The examiner must explain the rationale for all opinion, and is asked to specifically comment on the June 2012 statement by Dr. T. Wiginton (indicating the Veteran has had glaucoma since service), indicating whether or not there is any support in the factual data of record for Dr. Wiginton's conclusion. 3. The RO should then review the record and readjudicate the claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran 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 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). _________________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).