Citation Nr: 1330830 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 07-33 164 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a headache disorder, to include as secondary to service-connected residuals of right eye laser surgery. 2. Entitlement to a disability rating in excess of 10 percent for residuals of right eye laser surgery. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran served on active duty from October 1976 to November 1997. This matter comes to the Board of Veterans' (Board) on appeal from a September 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran's claims were previously before the Board and remanded for additional development in September 2011. As will be explained in greater detail below, there was compliance with all remand directives, and the Board may proceed with this adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A review of the Veteran's virtual VA claims files shows that they contain only evidence that is duplicative of that already contained in the claims file or irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran has not been shown to currently have a headaches disorder that is related to his military service or to his service-connected residuals of laser surgery. 2. The Veteran's residuals of right eye laser surgery are manifested by corrected distant visual acuity no worse than 20/50. There is no impairment of visual field or muscle function. CONCLUSIONS OF LAW 1. A headache disorder was not incurred in active service and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 101(21), (24), 106, 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a disability rating in excess of 10 percent for residuals of right eye laser surgery have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.79, Diagnostic Code 6011 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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). Proper notice from 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the appellant's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, notice dated in January 2006 informed the Veteran of what evidence VA would seek to provide and what evidence the Veteran was responsible for providing with regard to his service connection and increased rating claims. He was informed that, in order to substantiate his claim, the evidence needed to show that his service-connected disability had worsened. He was also told how to substantiate his claim for service connection, to include on a secondary basis. In an April 2006 letter, the Veteran was provided with notice compliant with the requirements outlined in Dingess/Hartman. Thereafter, the Veteran's claims were initially adjudicated in September 2006. A December 2007 supplemental statement of the case contained the rating criteria used to evaluate his service-connected disability. Therefore, the Veteran had actual knowledge of the code used to determine his rating. That claim was thereafter readjudicated in a May 2012 supplemental statement of the case. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). As such, the duty to notify has been satisfied for both of the claims on appeal. VA also has a duty to assist the Veteran in the development of the claims. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). In this case, the RO has secured all of the pertinent medical records identified by the Veteran, which consists of service treatment records, private records, and VA treatment records. Furthermore, he was afforded a VA examination pertinent to his service connection claim in October 2011, see McLendon v. Nicholson, 20 Vet. App. 79 (2006), and VA examinations pertinent to his increased rating claim in May 2006, December 2007, and October 2011. All examinations were conducted by medical professionals who, where appropriate, reviewed the claims file, solicited history and symptomatology, evaluated the Veteran, and provided conclusions based upon clear rationales. The examinations are adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In compliance with the Board's September 2011 remand, the RO sent the Veteran a letter in September 2011 requesting him to provide information regarding any outstanding relevant medical records. The Veteran did not respond. In addition, the Veteran was afforded VA examinations in October 2011 that were fully responsive to the remand directives contained in the Board's directives. Therefore, the Board may proceed with this appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Service Connection for Headaches As an initial matter, the Board notes that the Veteran does not allege, and the evidence does not reflect, that the disability for which he claims entitlement to service connection is the result of participation in combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Since the diagnosis claimed herein is not an enumerated chronic disease, the provisions of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disease first 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). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of 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). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The provisions of 38 C.F.R. § 3.310 were amended, effective from October 10, 2006; however, the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen v. Brown, 7 Vet. App. 439 (1995), the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. On reports of medical history completed in May 1989 and August 1992, the Veteran denied having a history of frequent or severe headaches. A March 1993 service treatment record shows that the Veteran complained of on and off headaches for one week, along with complaints of a sore throat, cough, green mucus, and nasal congestion. In September 1994and September 1997 reports of medical history, the Veteran once again denied a history of frequent or severe headaches. On examination in September 1997, the Veteran's head and vascular system were normal. In a September 1998 claim, the Veteran did not claim entitlement to service connection for headaches. A November 2002 private treatment record shows that the Veteran complained of headaches. A November 2005 private report also shows that the Veteran complained that he recently experienced occasional severe headaches. He reported that they were occurring more often. In a December 2005 written statement, the Veteran indicated that he had been experiencing headaches since his last evaluation. In a subsequent February 2006 written statement, the Veteran noted that his headaches caused him to have trouble sleeping at times. He felt them behind the eye in which he had the laser surgery. He stated that the headaches were daily and almost unbearable. In May 2006, the Veteran underwent a VA examination during which described daily headaches that have occurred since his laser surgery. He indicated that he experienced them behind his right eye. He usually took over-the-counter medication and went to sleep after which they would go away. The headaches have been relieved by Fioricet in the past. The diagnosis was a history of headaches, and the examiner concluded that there was no ocular etiology found on examination for the headaches. In October 2011, the Veteran underwent another VA examination during which tension headaches were diagnosed. He described experiencing a pulsating or throbbing pain that was localized to one side of the head. He also had pressure pain. He indicated that the headaches were on the right side of his head and lasted for hours. He did not have characteristic prostrating attacks of migraine or non-migraine headache pain. The examiner reviewed the claims file and noted a February 1997 record of an optometry examination in which the Veteran checked a box indicating that he had frequent or recurrent headaches. However, he also observed that there were multiple other times in service when the Veteran denied having frequent or severe headaches, including his September 1997 separation examination. The Veteran's in-service denials of a history of headaches were also noted. It was also noted that he had a headache associated with a viral syndrome in March 1993. Based on a review of the medical records, medical literature, and his own clinical experience as a neurologist, the October 2011 VA examiner concluded that there is absolutely no evidence of any chronic headache disorder in service or for several years thereafter. He also stated that there is no nexus between the Veteran's current headache disorder and his military service. The examiner further opined that there is no connection between his headaches disorder and his service-connected residuals of right eye laser surgery. There was no reason for the surgery to cause or aggravate the headaches disorder, as the Veteran had the surgery over 10 years before any documented headache problems. Thus, the examiner concluded that the Veteran's headaches disorder was no caused by, a result of, or aggravated by his military service and service-connected residuals of right eye laser surgery. In considering 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 a headache disorder. Although there were complaints of headaches in service, the Board notes that the Veteran subsequently denied having a medical history of frequent or severe headaches. Indeed, he denied having such problems during his September 1997 separation examination, and a clinical evaluation was normal at that time. Thus, there is affirmative evidence showing that he did not have a headache disorder when he separated from service. As such, it appears that any such symptomatology in service was acute and transitory and resolved prior to his military service. In support of this finding, the Board notes that the October 2011 VA examiner reviewed the service treatment records and found that there was no headache disorder in service. Moreover, following service, the first documented complaints of headaches were made in November 2002. In fact, the Veteran indicated in November 2005 that he recently began experiencing occasional, severe headaches, which also suggests an onset after service. He has not alleged otherwise. With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of a headache disorder, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). In addition to the lack of evidence showing that a headache disorder manifested during active duty service or within close proximity thereto, the more probative evidence of record does not link any current diagnosis of a headache disorder to the Veteran's active service or to his service-connected residuals of right eye laser surgery. There are three opinions of record that address whether the Veteran's headaches are related to his military service or his service-connected right eye disability. Those are the opinions provided by the Veteran, the May 2006 VA examiner, and the October 2011 VA examiner. First, the Board finds that the opinion provided by the May 2006 VA examiner has little probative value. While the examination appears to be thorough, the examiner provides an opinion and conclusion without giving a rationale to support the finding. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Sklar v. Brown, 5 Vet. App. 140 (1993). Therefore, this opinion is given little probative weight on this matter. As to the Veteran's opinion, the Board notes that laypersons are often able to provide competent opinions regarding medical matters, such as etiology and diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds that the opinion provided by the October 2011 VA examiner is more probative than the Veteran's lay assertions. The opinion was provided by a medical doctor, who has specialized training, experience, and education that the Veteran, as a layperson, is not shown to have. The opinion was well-reasoned and supported by a review of the claims file. It included a specific discussion of the Veteran's reported history of symptomatology and addressed service connection on both a direct and secondary basis. The conclusion provided by the examiner was accompanied by a detailed rationale that incorporated both the Veteran's specific history and accepted medical principles. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). For these reasons, the Board finds that the opinion of the October 2011 VA examiner is more probative than the opinion provided by the Veteran. Thus, the more probative evidence of record weighs against the claim. The Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a headache disorder. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for a headache disorder is not warranted. Increased Rating for Right Eye Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Whether this is considered a situation where entitlement to compensation has already been established and an increase in the disability rating is at issue, or one in which an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, staged ratings are appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Here, however, as shown below, separate evaluations are not warranted for any stage of the appeal period. The Veteran's residuals of right eye laser surgery is currently assigned a 10 percent evaluation pursuant to 38 C.F.R. § 4.79, Diagnostic Code 6011. That code provides the rating criteria for retinal scars, atrophy, or irregularities. It states that localized scars, atrophy, or irregularities of the retina, unilateral or bilateral, that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image are assigned a 10 percent rating. This is the only schedular rating available under that diagnostic code. Diagnostic Code 6011 then indicates that, alternatively, the disability may be evaluated based on visual impairment due to retinal scars, atrophy, or irregularities, if this would result in a higher evaluation. The criteria of 38 C.F.R. § 4.75(c) indicate that, subject to the provisions of 38 C.F.R. § 3.383(a), if visual impairment of only one eye is service-connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of evaluating the service-connected visual impairment. The provisions of 38 C.F.R. § 3.383(a)(1) indicate that impairment of the non-service-connected eye will be considered if the impairment in that eye is not the result of the Veteran's own willful misconduct and (i) the impairment of vision in each eye is rated at a visual acuity of 20/200 or less; or (ii) the peripheral field of vision for each eye is 20 degrees or less. As will be shown below, the Veteran's vision does not satisfy these criteria. Thus, the Board will evaluate the disability as if the non-service-connected left eye has vision of 20/40, pursuant to 38 C.F.R. § 4.75(c). The Veteran underwent VA examinations in May 2006, December 2007, and October 2011. There are also numerous VA outpatient treatment records containing eye examinations of record that are dated throughout the appeal period. None of this evidence suggests that visual acuity of either eye was ever evaluated as 20/200 or less or that the peripheral field of vision for each eye was 20 degrees or less. The Veteran has never contended that this is the case. Therefore, for rating purposes, the vision in the Veteran's non-service-connected left eye will be considered to be 20/40. Thus, in order to warrant a rating in excess of 10 percent under the pertinent criteria, the visual acuity of the Veteran's right eye must be evaluated as 20/200. 38 C.F.R. § 4.79, Diagnostic Code 6066. As stated above, none of the evidence of record, to include three VA examinations, numerous VA outpatient treatment records, and the Veteran's written statements, suggests that his right eye ever demonstrated visual acuity of 20/200 or less. The Veteran's visual acuity is shown, at its worst, to be 20/50, which is documented in a February 2009 VA outpatient treatment record. This result was obtained based upon corrected distance testing, as is required under the criteria of 38 C.F.R. § 4.76. In addition, none of the evidence of record suggests that the lens needed to correct distant vision in the poorer right eye differs by more than three diopters from the lens required to correct distant vision in the better left eye. Nevertheless, even uncorrected vision in the right eye is never shown to be 20/200 or worse. In addition, visual field testing was full to finger count in both eyes on examination in May 2006. The December 2007 VA examination report shows that there was no visual field defect. On examination in October 2011, visual field testing revealed that the Veteran did not have loss of a visual field. In order to warrant a higher rating for visual field impairment, the Veteran would have to demonstrate homonymous hemianopsia or concentric contraction of visual field with remaining field of 6 to 15 degrees. 38 C.F.R. § 4.79, Diagnostic Code 6080. Because peripheral field of vision for each eye is not 20 degrees or less, the service-connected right eye must be evaluated without considering the visual field results of the non-service-connected left eye. Nevertheless, visual field testing of the left eye has never met the criteria for a rating in excess of 10 percent under these criteria. Finally, there is no evidence of diplopia or symblepharon. While the Veteran appeared to have suggested that he had double vision in an April 2007 written statement, all of the medical evidence of record shows that diplopia is not a diagnosis attributable to the Veteran's right eye. The findings of medical professionals are more probative on this matter than the Veteran's bare lay statements, and the Board finds that evaluation under the criteria associated with diplopia is not warranted. The Veteran has complained of symptomatology related to his right eye residuals, and he is certainly competent to do so. Layno v. Brown, 6 Vet. App. 465, 469 (1994). To the extent that he contends that the vision in his right eye has worsened, the Board has determined that the specific findings on examination as to exactly what level of impairment is present are more probative than the Veteran's general complaints. Lastly, the Board notes that the Veteran has never demonstrated the level of vision impairment needed for consideration for special monthly compensation. See 38 C.F.R. § 3.350. Given a review of all of the evidence and the foregoing analysis, the Board finds that the evidence preponderates against a finding that a disability rating in excess of 10 percent is warranted for residuals of right eye laser surgery, and the Veteran's claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Extraschedular Consideration In exceptional cases where schedular evaluations are found to be inadequate, the RO or Board may refer a claim to the Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of "an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). "The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. The Board may not award benefits under 38 C.F.R. § 3.321(b)(1) in the first instance, but may adjudicate whether a referral to the appropriate officials is warranted. Floyd, 9 Vet. App. at 95. When extraschedular consideration is raised, "if the case is not referred to the RO for referral...for consideration of an extraschedular rating evaluation, the Board must provide an adequate statement of reasons or bases for its decision not to so refer it." Colayong v. West, 12, Vet. App. 524, 537 (1999); see Bagwell v. Derwinski, 9 Vet. App. 337, 339 (1996). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). Under Thun, therefore, the threshold question is whether the rating criteria for the Veteran's residuals of right eye laser surgery reasonably describe and contemplate the extent and severity of these disabilities, including his specific symptoms. See Thun, 22 Vet. App. at 115. In other words, "[t]here must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Id. See also VA Gen. Coun. Prec. 6-1996 (Aug. 16, 1996), para 7 (when service-connected disability affects employment "in ways not contemplated by the rating schedule" § 3.321(b)(1) is applicable). Also, an inadequacy of the rating schedule cannot be established solely by showing an asserted gap between the Veteran's income and the income of similarly qualified workers in his field. Thun, 22 Vet. App at 116. If the Board finds that the schedular 10 percent rating does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, only then is the Board required to go the second step to determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms"-namely, marked interference with employment or frequent periods of hospitalization. In this case, the Veteran has complained of a black spot in the vision of his right eye as well as seeing curved lines where they should be straight, which was diagnosed as mild metamorphopsia on examination in October 2011. Both of these symptoms are contemplated in the rating criteria, which evaluate visual acuity and also contemplate an irregular, duplicated, enlarged, or diminished image. The only symptom complained of by the Veteran that is not specifically enumerated in the rating criteria is pain. The Veteran indicated in written statements that he experienced pain in his right eye, which sometimes interfered with his sleep. However, turning to the second step outlined in Thun, this symptom of pain does not exhibit other related factors, such as those provided by the regulation as "governing norms." There is no lay or medical evidence of hospitalization due to the right eye disability during the appeal period. In addition, the Veteran indicated in a December 2005 written statement that he conducted his duties to the best of his ability and noted that his supervisor had nothing but good things to say about his job performance. While he had to push himself harder to accomplish his daily missions, this does not correlate to marked interference with employment. Finally, no medical evidence suggests that the Veteran's right eye disability impacts his employment. In fact, the October 2011 VA examiner specifically indicated that it did not impact his ability to work. Therefore, the Board concludes that the Veteran's right eye disability and complaints pain do not result in frequent hospitalization or marked interference with employment. In light of this finding, the Board is not required to consider the third step outlined in the Thun decision because referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 116. For these reasons and bases, the Board finds that referral of this case to the Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of extraschedular ratings for his residuals of right eye laser surgery is not warranted. Accordingly, the appeal is denied. ORDER Service connection for a headache disorder, to include as secondary to service-connected residuals of right eye laser surgery, is denied. A disability rating in excess of 10 percent for residuals of right eye laser surgery is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs