Citation Nr: 1328203 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 08-22 473 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis. 2. Entitlement to service connection for residuals of a right eye injury. 3. Entitlement to service connection for a psychiatric disorder other than a personality disorder or schizoaffective disorder. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1977 to September 1978. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. Jurisdiction of the case was subsequently transferred to the RO in Louisville, Kentucky. In February 2012, the Board, among other things, denied both the Veteran's application to reopen a claim of service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis and his claim of service connection for a psychiatric disorder other than a personality disorder or schizoaffective disorder. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In January 2013, the Court granted a Joint Motion for Partial Remand (JMPR) filed by the parties and remanded the portion of the Board's order denying the claims as stated above. The February 2012 Board decision also reopened the claim of service connection for residuals of a right eye injury and remanded the merits for further development. The issue of entitlement to service connection for a psychiatric disorder other than a personality disorder or schizoaffective disorder 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. In a February 1990 rating decision, the RO denied the Veteran's application to reopen his claim of service connection for a right eye disorder. The Veteran was notified of this decision the following month and did not appeal this decision or submit new and material evidence within the one-year appeal period. 2. Evidence received since the February 1990 rating decision is essentially cumulative or redundant of the evidence previously of record or does not relate to an unestablished fact necessary to substantiate the claim of service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis. 3. The Veteran has been shown to have residuals of a right eye injury, manifested by reduced visual acuity, that are related to service. CONCLUSIONS OF LAW 1. The February 1990 rating decision that denied the application to reopen the claim of service connection for a right eye disorder is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.156(b), 20.1103 (2012). 2. Evidence received since the February 1990 rating decision is not new and material as to the claim of service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis, and reopening of this claim is therefore not warranted. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. Resolving all reasonable doubt in favor of the Veteran, residuals of a right eye injury were incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to claim for entitlement to service connection for residuals of a right eye injury, because the claim is granted, VA's duties to notify and assist are deemed fully satisfied and there is no prejudice to the Veteran in proceeding to decide that issue on appeal. See 38 U.S.C.A. §§ 5103, 5103A, 5107(West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2012). Regarding the petition to reopen a claim for entitlement to service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis, VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA must inform the claimant of any information and medical or lay 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. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the notice requirements 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. 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Specific to requests to reopen, a claimant must be notified of both the reopening criteria and the criteria for establishing the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The Veteran was provided adequate VCAA notice in a November 2006 pre-rating letter, to include an explanation that his claim was denied because the service treatment records (STRs) showed normal right eye vision, the criteria for establishing new and material evidence and service connection, and information about disability ratings and effective dates. He was again provided notice in August 2007 and June 2010 letters. The Board notes that the initial notice letter listed the September 1987 rating decision denying service connection for blepharitis, but it did not specifically list the most recent denial of the application to reopen in February 1990. In any event, the Board finds that this omission does not prejudice the Veteran, since the RO identified the most recent prior denial on the merits of the claim and provided the basis for the prior denial. Moreover, there is no question of the finality of either decision, and the Veteran received the necessary pre-rating information to substantiate his current claim. The VCAA also requires VA to 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. The record reflects that all pertinent available service treatment records and all available post-service medical evidence identified by the Veteran have been obtained. The Veteran's written statements are also of record. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. The Veteran was afforded an opportunity to present testimony at a hearing before the Board; however, he failed to appear for the hearing without explanation. The Board notes that the duty to assist does not arise until new and material evidence sufficient to reopen the claim has been received. Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1342-43 (Fed. Cir. 2003) ("[I]n the absence of new and material evidence, VA is not required to provide assistance to a claimant attempting to reopen a previously disallowed claim, including providing a medical examination or obtaining a medical opinion."); Woehlaert v. Nicholson, 21 Vet. App. 456, 463 (2007). Nonetheless, to the extent the RO considered the entire right eye claim reopened prior to bifurcation of the issue by the Board in the February 2012 decision, the Veteran was afforded an appropriate VA examination in June 2010. The Board finds that the examination was adequate, in that it was conducted by a medical professional who reviewed the claims file, solicited history from the Veteran, and performed a thorough examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In October 2010, the Veteran was scheduled for a hearing before a Veterans Law Judge at the RO; he failed to appear without explanation. He has not submitted a request to reschedule the hearing since that time. As such, the Veteran's hearing request is deemed withdrawn. 38 C.F.R. § 20.704 (2012). A review of the Virtual VA and VBMS electronic claims files reveals additional evidence of the Veteran's ongoing VA treatment. However, the RO's most recent May 2013 supplemental statement of the case (SSOC) reflects consideration of this evidence in relation to the right eye. To the extent this SSOC did not specifically contemplate this evidence for the claim to reopen (as this issue was appealed to the Court and not subsequently remanded to the RO), the Board finds that the evidence in these electronic records is not pertinent to that claim (i.e., does not have a bearing on the outcome of the appellate issue), and therefore, remand for initial RO review of this evidence in this regard is not necessary. 38 C.F.R. §§ 19.37, 20.1304(c) (2012). Based on the foregoing, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. Bernard v. Brown, 4 Vet. App. 384 (1993). Finally, this appeal was remanded by the Court in January 2013. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). That remand requested that the Board address a June 1989 treatment record in the adjudication of the claim to reopen. This is addressed below. Accordingly, the Board finds that there has been substantial compliance with the JMPR and it may proceed to adjudication of this appeal. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). II. Legal Principles and Analysis New and Material Evidence Generally, a claim which has been denied in a final unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence is defined as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted to reopen a claim, the credibility of evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118. According to the plain language of 38 C.F.R. § 3.156(a), however, evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343, 1347 (Fed. Cir. 2000). New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous denial and evidence submitted thereafter. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). Historically, the Veteran was denied service connection for an eye injury in a March 1979 rating decision. In 1987, the Veteran was treated for blepharitis (inflammation of the eyelids) of both eyes during a VA psychiatric hospitalization; a September 1987 rating decision amended the prior rating decision to address this additional diagnosis and continued to deny service connection for the right eye. In October 1988, the RO issued an SOC. Thereafter, the Veteran did not complete his appeal. In April 1989, the Veteran attempted to reopen the claim for service connection for a right eye disorder, claimed as loss of vision. The February 1990 rating decision denied reopening finding new and material evidence had not been submitted; this was the last final denial of the claim of service connection for a right eye disorder, including residuals of a right eye injury and blepharitis. The April 2007 rating decision continued to treat the claims as one issue for adjudication purposes. Thereafter, the February 2012 Board decision adjudicated the right eye issues separately, as shown in the issues as stated in this decision, reopening and remanding the claim of residuals of a right eye injury and denying reopening of the claim of blepharitis; both claims are discussed in the decision below. In the February 1990 rating decision, the RO denied the Veteran's application to reopen his claim of service connection for a right eye disorder, claimed as "loss of vision" as a result of in-service trauma to the eye. The RO based this determination on the lack of evidence of an in-service eye injury. The Veteran was notified of this decision, but he did not appeal or submit new and material evidence within the one-year appeal period. Therefore, this decision became final. See 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. The evidence of record in February 1990 consisted of the Veteran's STRs, which showed multiple reports of in-service complaints and treatment for eye symptoms. In March 1978, he complained of blurred vision, among other things, and was given an assessment of a viral syndrome. Later that month, he complained of burning and itching in both eyes; visual acuity in the right eye was measured as 20/20, and an assessment of "?" was provided. A May 1978 STR shows that the Veteran reported that he was unable to see out of his right eye at intervals; visual acuity was measured as 20/40. A June 1978 treatment record shows that the Veteran continued to complain of a decrease in visual acuity in the right eye; notations were made that the Veteran denied a history of amblyopia (lazy eye) but reported a history of trauma to the eye two weeks prior. On examination, the Veteran complained of photophobia of the right eye. On additional examination thereafter, an impression of possible macular and/or corneal edema was provided; another examination revealed a diagnosis of possible migraine headaches. Following a September 1978 ophthalmology consultation for continuing complaints, the doctor determined that there was no right eye abnormality noted and recorded the Veteran's corrected vision as 20/20. The separation examination report from that same month (addressing the eyes only, in addition to the Medical Board psychiatric findings) confirmed the determination of the ophthalmology consultation noting no abnormalities and corrected vision in the right eye of 20/20. The Veteran was treated for blepharitis during a 1987 VA hospitalization; treatment included cleaning the eyelids and topical ointment. The evidence received since February 1990 consists of a June 1989 evaluation report, VA treatment records showing a history of treatment for both eyes, VA eye examinations in June 2010 and April 2013, and Veteran and representative statements. The evidence added to the record does not include evidence, other than the Veteran's own assertions, that blepharitis is related to service. A June 1989 evaluation report from Dr. A.E. shows a history of decreased vision in the right eye following a contusion injury from being hit with an "olive seed" in 1978; the Veteran reported that he had a macular hole and had difficulty with his central vision in that eye. Following examination, the assessment was possible lamellar hole of the macula, right eye, with decreased central vision (noted inconsistency in the actual level of visual acuity), and marginal blepharitis. A November 2006 VA ophthalmology treatment record shows a history of prior right eye trauma. Following examination, the assessment was traumatic focal macular disruption, decreased visual acuity, right eye, and refractive error. Thereafter, a November 2007 VA record found the eyes to be generally stable. A March 2010 VA treatment record shows that the Veteran continued to report a history of blunt force trauma to the right eye; he also reported that he was told he had a macular hole which was now healed. The assessment noted this history as well as distorted vision in the right eye, as well as myopia, astigmatism, and presbyopia. A May 2010 VA treatment record shows that he complained of difficulty using his new computer glasses but had no additional ocular complaints. Following examination, no additional disorders were noted. The Veteran underwent VA examination in June 2010, during which he reported the in-service injury to his right eye as discussed above and that he was told that he had a macular hole which was now healed. The examiner did not assign a diagnosis of blepharitis and concluded that it was not likely that blepharitis was related to the Veteran's service. In addition, while the examiner noted current right eye vision loss, she did not provide an opinion on etiology, to include whether the vision loss was related to the in-service injury. In a May 2011 written brief, the Veteran's representative argued that reopening of the Veteran's right eye claim was warranted in light of the current evidence of a macular deformity secondary to in-service trauma to the eye. In February 2012, the Board remanded the claim of residuals of a right eye injury for a VA examination to address the cause of any reduced visual acuity or vision loss in the right eye. The Veteran underwent another VA examination in April 2013, during which he again reported the in-service injury and that he was told that he had a macular hole and subsequent reduced vision thereafter. On examination, the Veteran had reduced visual acuity in the right eye, noted to be due to pigmentary changes and macular changes, as well as a reduced visual field. The examiner stated that the Veteran's history of a macular hole and subsequent reduced visual acuity was most likely related to trauma to the eye during service. The examiner also stated that the reduced visual field was less likely as not related to the macular hole. On review of the evidence above, the Board finds that the evidence received since February 1990 is not material to the claim to reopen service connection for a right eye disorder other than residuals of a right eye injury, including blepharitis. Nothing in the medical evidence added to the record relates to the reason why the claim was originally denied, i.e., no additional evidence shows or implies that the Veteran's intermittent blepharitis (noted as occurring, and apparently resolving, two times over the course of the claim history) is attributable to an event, injury, or disease in service. In this regard, Dr. A.E.'s evaluation report, while diagnosing marginal blepharitis, does not suggest that that diagnosis at that time was related to service; the diagnosis of possible lamellar hole of the macula is contemplated in the residuals of right eye injury discussed separately in this decision. The June 2010 VA examiner determined that the Veteran did not manifest blepharitis at that time, and concluded that it was not likely that blepharitis was related to the Veteran's service, which is not supportive of the claim. Although the Veteran's representative argued that this VA examination was inadequate in a May 2011 brief; that inadequacy was noted to be related to a failure to discuss the abnormality of the macula due to trauma, which is addressed separately herein. In addition, to the extent other right eye disorder diagnoses were provided during the course of the claim (e.g., myopia, refractive error), there is no suggestion in the record, nor does the Veteran contend that such a diagnosis is related to in-service circumstances. In sum, this evidence relates to current symptoms and does not show or imply any relationship between those symptoms and the Veteran's service such that the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. See Shade, 24 Vet. App. at 118 (application of "reasonable possibility portion of [§ ] 3.156(a) cannot impose a greater burden to reopening than imposed by Congress by that language in the VCAA."). The Board notes that the April 2013 VA examination was conducted in relation to the claim for residuals of right eye injury and did not note a finding of blepharitis. As such, to the extent that the RO did not fully contemplate this examination in relation to the application to reopen, the Board finds that this evidence is not pertinent to this issue, and decision by the Board at this time is therefore not prejudicial to the Veteran. The Board has also considered the Veteran's lay statements regarding his right eye symptomatology. Significantly, however, the Veteran essentially claims that he has macular changes due to trauma and does not appear to provide a clear statement supporting the claim for a right eye disorder other than residuals of the right eye injury. The Board also notes that while the record does not suggest, and the Veteran does not contend, that blepharitis is a residual of the in-service eye injury discussed in detail below, to the extent blepharitis could be considered as such, it is properly addressed in the discussion of this issue below. Under these circumstances, the Board concludes that new and material evidence to reopen the claim of entitlement to service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis, has not been received. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The disorder at issue is not considered a chronic disease as enumerated for VA compensation purposes. As such, the provisions for continuity of symptomatology after discharge are not for application in this case. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran contends that his current right eye disorder is related to service - specifically, an in-service injury where he was hit in the eye with either an olive pit or a piece of metal. In this regard, he has consistently asserted throughout the history of his claims process that he has right eye vision loss as a result of this injury. See, e.g., December 1978 original compensation claim; March 1979, August 1987, and September 1988 written statements; April 1989 claim; June 1989 private evaluation; November 2006 VA treatment record; June 2010 and April 2013 VA examination reports. A review of the Veteran's STRs shows multiple reports of in-service complaints and treatment for eye symptoms. In March 1978, he complained of blurred vision, among other things, and was given an assessment of a viral syndrome. Later that month, he complained of burning and itching in both eyes; visual acuity in the right eye was measured as 20/20, and an assessment of "?" was provided. A May 1978 STR shows that the Veteran reported that he was unable to see out of his right eye at intervals; visual acuity was measured as 20/40. A June 1978 record shows that the Veteran continued to report a decrease in visual acuity in the right eye; notations were made that the Veteran denied a history of amblyopia (lazy eye) but reported a history of trauma to the eye two weeks prior. On examination, the Veteran complained of photophobia of the right eye. On additional examination thereafter, an impression of possible macular and/or corneal edema was provided; another examination revealed a diagnosis of possible migraine headaches. Following a September 1978 ophthalmology consultation for continuing complaints, the doctor determined that there was no right eye abnormality noted and recorded the Veteran's corrected vision as 20/20. The separation examination report from that same month (addressing the eyes only, in addition to the Medical Board psychiatric findings) confirmed the determination of the ophthalmology consultation noting no abnormalities and corrected vision in the right eye of 20/20. As indicated above, the Veteran was treated for blepharitis during a 1987 VA hospitalization; treatment included cleaning the eyelids and topical ointment. A June 1989 private evaluation report shows a history of decreased vision in the right eye following a contusion injury from being hit with an "olive seed" in 1978; the Veteran reported that he had a macular hole and had difficulty with his central vision in that eye. Following examination, the assessment was possible lamellar hole of the macula, right eye, with decreased central vision (noted inconsistency in the actual level of visual acuity), and marginal blepharitis. A November 2006 VA ophthalmology treatment record shows a history of prior right eye trauma. Following examination, the assessment was traumatic focal macular disruption, decreased visual acuity, right eye, and refractive error. In a November 2007 VA treatment record, the eyes were found to be generally stable. A March 2010 VA record shows that the Veteran continued to report a history of blunt force trauma to the right eye; he also reported that he was told he had a macular hole which was now healed. The assessment noted this history as well as distorted vision in the right eye, as well as myopia, astigmatism, and presbyopia. A May 2010 VA record shows that he complained of difficulty using his new computer glasses but had no additional ocular complaints. Following examination, no additional disorders were noted. The Veteran underwent VA examination in June 2010, during which he reported the in-service injury to his right eye as discussed above and that he was told that he had a macular hole which was now healed. The examiner did not assign a diagnosis of blepharitis and concluded that it was not likely that blepharitis was related to the Veteran's service. In addition, while the examiner noted current right eye vision loss, she did not provide an opinion on etiology, to include whether the vision loss was related to the in-service injury. The Veteran underwent another VA examination in April 2013, during which he again reported the in-service injury and that he was told that he had a macular hole and subsequent reduced vision thereafter. On examination, the Veteran had reduced visual acuity in the right eye, noted to be due to pigmentary changes and macular changes, as well as a reduced visual field. The examiner stated that the Veteran's history of a macular hole and subsequent reduced visual acuity was most likely related to trauma to the eye during service. The examiner also stated that the reduced visual field was less likely as not related to the macular hole. Upon careful review of the record, the Board finds that service connection for residuals of a right eye disorder is warranted. The record indicates reduced visual acuity in the Veteran's right eye due to macular changes. The Board also finds that Veteran's reports of in-service eye trauma competent and credible. Furthermore, the record raises a reasonable doubt as to whether the Veteran's right eye reduced visual acuity was due to in-service circumstances. As noted above, although the STRs show complaints and treatment for eye problems, to include an impression of possible macular and/or corneal edema, a definitive diagnosis of a right eye disorder was not provided in service; examination of the eyes yielded normal results at separation. However, the Veteran has consistently contended that he sustained a blunt force trauma to the eye during service and that he has experienced vision difficulty with that eye since that time. Laypersons are competent to report as to observable symptoms and experiences, such as an onset of eye symptoms, and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Similarly, the Veteran is also competent to report information conveyed to him by his doctor, such as a contemporaneous medical diagnosis or opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau and Buchanan). The Board finds the Veteran to be competent and credible in his statements regarding the in-service eye injury. See Buchanan, 451 F.3d at 1336-37. In this regard, his reported history has remained consistent throughout the course of the appeal. Moreover, there is a history of eye trauma noted in the STRs and an assessment of traumatic focal macular disruption, decreased visual acuity in the VA treatment records, and there is no evidence of any intercurrent causes. His reports that his doctor told him that he had a macular hole as a result of trauma are also consistent with the VA treatment records noting macular changes. In addition, the April 2013 VA examiner incorporated the Veteran's report of in-service eye trauma into his opinion. A medical opinion formed on the basis of the Veteran's reported medical history cannot be rejected without the Board first finding that the Veteran's allegations are not credible. Coburn, 19 Vet. App. at 432-33. Here, the Board has found the Veteran's statements of in-service eye trauma and resulting residuals competent and credible, and the opinion based on this finding from the VA examiner, who reviewed the claims file in addition to examining the Veteran, provides evidence that the Veteran's history of macular changes and subsequent reduced visual acuity was most likely related to trauma to the eye during service. The Board also notes that there is no medical evidence showing otherwise. Although the June 2010 VA examiner indicated that blepharitis was not related to service, no opinion was provided as to the reduced visual acuity of the right eye. The Board has considered whether there were additional residuals attributable to the Veteran's right eye injury in service. However, the medical evidence of record, to include the June 1989 private evaluation, does not suggest that there are additional residuals of the trauma aside from the macular disruption resulting in reduced visual acuity. In addition, the June 2010 VA examiner found that any blepharitis was not due to service, and the April 2013 VA examiner found that the right eye reduced visual field found on examination was not due to the in-service injury, both based on review of the record. The Board also emphasizes that the Veteran's essentially sole contention through the many years of his claims process has been that he has reduced vision in the right eye as a result of this in-service trauma. Accordingly, and resolving all reasonable doubt in the favor of the Veteran, the Board concludes that service connection for residuals of a right eye injury, manifested by reduced visual acuity is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The application to reopen the claim of entitlement to service connection for a right eye disorder other than residuals of a right eye injury, to include blepharitis is denied. Entitlement to service connection for residuals of a right eye injury is granted. REMAND The Board finds that further development is necessary prior to final adjudication of the Veteran's claim of entitlement to service connection for a psychiatric disorder other than a personality disorder or schizoaffective disorder. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There is a current disability for VA purposes when a claimant has a disability at the time a claim is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) The Veteran filed his current claim in June 2007 and was afforded a VA examination in June 2010. That examiner noted a detailed review of the Veteran's mental health history, but found no Axis I diagnosis at that time, providing only Axis II diagnoses. But the record reflects a long history of diagnoses of Axis I psychiatric disorders and treatment following service. See, e.g., December 1989 SSA decision (depression, anxiety, posttraumatic stress disorder (PTSD), and personality disorder); 1992 private treatment records; 2001 SSA evaluation (schizophrenia, residual type; mental disorder due to seizures - provisional). The next records of psychiatric treatment, beginning in 2006, show diagnoses of PTSD and depression, some by history. See, e.g., June 2008, July 2009, November 2009, March 2010 VA treatment records. In the May 2011 brief, the Veteran's representative argued that the VA examination was inadequate because that the examiner did not fully contemplate the Veteran's psychiatric disorders diagnosed by other VA providers. Additionally, the January 2013 JMPR noted that the examiner did not consider the other diagnoses of record. The Board finds that the June 2010 VA examination, although quite thorough and well-supported in general, is legally inadequate because the examiner did not provide a clear opinion addressing the other mental health diagnoses present during the pendency of the claim. See McClain, 21 Vet. App. at 321. As such, the Board finds that an addendum medical opinion addressing the nature and etiology of any current mental health disorder is needed to have sufficient medical evidence to decide the claim. Accordingly, the case is REMANDED for the following action: 1. Forward the claims file to the VA psychiatrist who performed the June 2010 VA examination, or a suitable substitute if this examiner is unavailable, for a complete review and preparation of an addendum opinion addressing the nature and etiology of any current psychiatric disorder. An additional examination must be performed if deemed necessary. The supporting rationale for all opinions expressed must be provided. If the required opinion cannot be provided, the examiner should provide an explanation in the report. Specifically, the examiner should identify any psychiatric disorder present at the time of the June 2007 claim or otherwise during the pendency of the claim, to include the previously diagnosed PTSD and depression. See, e.g., June 2008, July 2009, November 2009, March 2010 VA treatment records. Then, for each diagnosed disorder, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that any such disorder manifested during or is otherwise related to service. 2. If upon completion of the above action any benefit sought remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. 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 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). ______________________________________________ K. MILLIKAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs