Citation Nr: 1331537 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 04-24 974A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUES 1. Entitlement to an initial evaluation for acute posterior multifocal placoid pigment epitheliopathy (bilateral eye disorder or APMPPE) in excess of 10 percent from July 5, 1989, to May 13, 1992; in excess of 40 percent from May 14, 1992, to July 11, 2002; and in excess of 80 percent from July 12, 2002, to March 27, 2003. 2. Entitlement to an initial evaluation in excess of 10 percent for residuals of Cryptococcus neoformans infection affecting the central nervous system. 3. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to July 12, 2002. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active duty from December 1971 to September 1973. In an August 1981 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut denied service connection for neurological disease with various manifestations, including headaches, a stiff neck, and vision problems, and, by implication, for APMPPE and the residuals of Cryptococcus neoformans infection affecting the central nervous system. The Veteran did not appeal that decision. In a November 1989 rating decision, the RO in Togus, Maine denied a claim of entitlement to service connection for multiple sclerosis. The Veteran subsequently perfected a timely appeal with respect to that issue. The Veteran's appeal was later expanded to include claims of entitlement to service connection for a disorder of the central nervous system other than multiple sclerosis; and entitlement to service connection for an eye disorder. The appeal was also expanded to include claims of service connection for a back disorder and for the residuals of exposure to toxic chemicals in service. Ultimately, in an August 2003 rating decision, the RO granted service connection for the residuals of Cryptococcus neoformans infection affecting the central nervous system, and assigned a 10 percent rating, effective July 5, 1989. The RO also granted service connection for APMPPE and assigned a 10 percent evaluation effective from July 5, 1989, a 40 percent evaluation effective from May 14, 1992, an 80 percent evaluation effective from July 12, 2002, and a 100 percent evaluation effective from March 28, 2003. The Veteran subsequently perfected an appeal regarding the disability ratings assigned in the August 2003 rating decision. Because the evaluations are less than the maximum under the schedular criteria, the matter of an increased rating remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993) (holding that, where there is no clearly expressed intent to limit the appeal, VA is required to consider entitlement to all available evaluations for that disorder). With respect to the bilateral eye disorder, the issue is characterized to reflect that "staged" ratings are assigned from July 5, 1989 and that all three "stages" are for consideration. Also, in the August 2003 decision, the RO granted a TDIU, effective from July 12, 2002 (the effective date of the 80 percent rating for APMPPE). The Veteran did not initiate an appeal with respect to the effective date assigned, and the RO considered this a full grant of the benefit sought on appeal. Although the TDIU issue has not been certified to the Board, when evidence of unemployability is received during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered "part and parcel" of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Inasmuch as a TDIU may be available prior to July 12, 2002, and the Veteran has indicated that he has been unemployed since 1986 due to service-connected disability, the Board finds that the TDIU issue is part of the pending appeal. In August 2004, the Veteran testified at a videoconference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing was prepared, and has been associated with the claims file. This case was then remanded by the Board in November 2005, December 2008 and August 2012 for additional development. The Board has reviewed both the Veteran's physical claims file and the record maintained in the Virtual VA (VVA) paperless claims processing system to ensure complete consideration of all the available evidence. The issues of entitlement to an initial evaluation in excess of 10 percent for residuals of Cryptococcus neoformans infection affecting the central nervous system and entitlement to TDIU prior to July 12, 2002 are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. From July 5, 1989 forward the Veteran has experienced active pathology due to his bilateral eye disorder diagnosed as APMPPE. 2. Affording the Veteran the benefit of the doubt, from July 5, 1989 to May 13, 1992, his APMPPE was manifested by subjective complaints of light sensitivity and double vision as well as objective findings of corrected visual acuity of no worse than 20/30 in both eyes and concentric contraction of the visual field to 41 degrees (or 20/70 visual acuity) on the right and 37 degrees (or 20/70 visual acuity) on the left. 3. From May 14, 1992, to July 11, 2002, the Veteran's APMPPE was manifested by subjective complaints of light sensitivity and double vision as well as objective findings of corrected visual acuity of no worse than 20/70 in both eyes and concentric contraction of the visual field to 49 degrees (or 20/50 visual acuity) on the right and 48 degrees (or 20/50 visual acuity) on the left. 4. From July 12, 2002 to March 27, 2003, the Veteran's APMPPE was manifested by corrected visual acuity of no worse than 20/200 in both eyes and continuing active pathology; with no clinical findings of loss of field vision shown. CONCLUSIONS OF LAW 1. From July 5, 1989 to May 13, 1992, the criteria for a 40 percent disability rating, but no higher, for the service-connected APMPPE were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.75, 4.76, 4.76a, 4.84a, Diagnostic Codes (DCs) 6008, 6061-6079, 6080 (as in effect prior to December 10, 2008). 2. From May 14, 1992, to July 11, 2002, the criteria for an initial disability rating in excess of 40 percent for APMPPE were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); §§ 4.75, 4.76, 4.76a, 4.84a, DCs 6008, 6061-6079, 6080 (as in effect prior to December 10, 2008). 3. From July 12, 2002 to March 27, 2003, the criteria for an initial disability rating in excess of 80 percent for APMPPE were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); §§ 4.75, 4.76, 4.76a, 4.84a, DCs 6008, 6061-6079, 6080 (as in effect prior to December 10, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Where, as here, service connection has been granted and the initial rating has been assigned, the claim of entitlement to service connection has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). [In any event, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board.] The Board also finds VA has satisfied its duty to assist the Veteran in the development of the increased rating claim adjudicated herein. His in-service and pertinent post service treatment reports are of record. The Veteran has availed himself of the opportunity to submit relevant evidence and argument in support of his claim, including testimony at a Board hearing in August 2004. Discussion of this hearing is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issue of entitlement to an increased rating for APMPPE was identified. Information was elicited from the Veteran concerning the nature and severity of his eye disability. Such triggered the Board's determination, in pertinent part, that a remand was necessary to obtain outstanding treatment records, which were requested and obtained on remand. The Board would note that during the long course of this appeal, the Veteran has been very prolific in his submissions to the VA with respect to his claim as evidenced by the eight volumes of evidence already obtained. His numerous written contentions with regard to his increased rating claim, including the information and research he has supplied from the internet, have been carefully considered. Following review of the extensive record, the Board finds that neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Board is also satisfied that the AMC has substantially complied with its August 2012 remand directives as they pertain to the increased rating matter decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). A VA examination of the Veteran's bilateral eye disorder was obtained in September 2012 and an addendum to that opinion was provided in April 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the 2012 examination along with the 2013 addendum opinion are adequate for rating purposes. In addition to performing quantitative measurements of the Veteran's visual acuity and field of vision, the physician also interpreted graphical representations of visual field testing from previous charts in December 1988 and May 1998. Specifically, the examination report and opinion contain sufficient evidence by which to evaluate the Veteran's bilateral eye claim in the context of the rating criteria. See generally 38 C.F.R. § 3.159(c)(4). There is no basis to conclude that the VA medical opinions are inadequate or that a remand for a new examination is required. Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence, to support his claim. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. Accordingly, the Board will adjudicate the claim on the merits. Law and Analysis The Veteran contends that his service-connected bilateral eye disorder (APMPPE) is more disabling than is reflected in the current 10 percent, 40 percent, and 80 percent disability staged ratings. Throughout the period on appeal, the Veteran has contended that he experiences light sensitivity, double vision, distorted vision (vision in which objects appear larger in one eye than the other), and flashes of light. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, 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 will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). As noted previously, the Veteran's claim arises from an August 2003 rating decision which established service connection for APMPPE. The RO assigned a 10 percent disability rating, effective from July 5, 1989; a 40 percent disability rating effective from May 14, 1992; an 80 percent disability rating effective from July 12, 2002, and a 100 percent disability rating, effective from March 28, 2003. The Veteran disagreed with the disability ratings assigned to his service-connected eye disorder, which is the basis of the current appeal. Thus, the portion of the appeal remaining unresolved is the ratings for the Veteran's APMPPE prior to March 28, 2003. The Board notes that during the pendency of the appeal, the applicable rating criteria for eye disabilities, found at 38 C.F.R. §§ 4.75 to 4.84a, were amended effective December 10, 2008. The December 2008 revisions are only applicable to claims received by VA on or after December 10, 2008. See 73 Fed. Reg. 66,543-66,554 (November 10, 2008). As the present claim was filed before that date, the changes are not applicable. The Veteran's bilateral eye disorder, diagnosed as APMPPE is currently rated under the provisions of DCs 6008-6075. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate detachment of the retina under DC 6008 as the service-connected disorder, and impairment of central visual acuity under DC 6075 as a residual disabling condition. According to DC 6008, ratings for chronic retinal detachment and other diseases of the eyes listed in DCs 6000 through 6009 (uveitis, keratitis, scleritis, iritis, cyclitis, choroiditis, retinitis, recent intra-ocular hemorrhage, and unhealed injury of the eye) are to be rated from 10 to 100 percent under the criteria for impairment of visual acuity or field loss, pain, rest-requirements or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. The minimum rating during active pathology is 10 percent. 38 C.F.R. § 4.84a. In making this assessment, the best distant vision obtainable after best correction with glasses will serve as the basis of the rating, except in cases of keratoconus, where lenses are medically required. 38 C.F.R. § 4.75. The severity of visual acuity loss is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. Under these criteria, impairment of central visual acuity is evaluated from noncompensable to 100 percent based upon the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, DCs 6061 to 6079. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a, Table V. A 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, DCs 6078, 6079 (2008). A 20 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/50; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, DCs 6077, 6078 (2008). A 30 percent evaluation will be assigned where: (1) corrected visual acuity in both eyes is 20/70; (2) corrected visual acuity in one eye is 20/100 and the other eye is 20/70; (3) corrected visual acuity in one eye is 20/200 in one eye and 20/50 in the other eye; (4) corrected visual acuity in one eye is 15/200 and 20/50 in the other eye; (5) corrected visual acuity in one eye is 10/200 and 20/40 in the other eye; (6) corrected visual acuity in one eye is 5/200 and 20/40 in the other eye ; or (7) blindness of one eye and corrected vision to 20/40 in the other eye. 38 C.F.R. § 4.84a, DCs 6070, 6074, 6076, 6077, 6078 (as in effect prior to December 10, 2008). A 40 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and 20/70 in the other eye; (2) corrected visual acuity of one eye is to 15/200 and 20/70 in the other eye; (3) corrected visual acuity in one eye is to 10/200 and 20/50 in the other eye; (4) corrected visual acuity is to 5/200 in one eye and 20/50 in the other eye; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/50 and 20/40, respectively, in the other eye. 38 C.F.R. § 4.84a, DCs 6066, 6070, 6073, 6076 (2008). A 50 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity is to 20/100 in both eyes; (2) corrected visual acuity is to 10/200 in one eye and to 20/70 in the other eye; (3) corrected visual acuity is to 5/200 in one eye and 20/70 in the other eye; or (4) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/70 and 20/50, respectively. 38 C.F.R. § 4.84a, DCs 6065, 6069, 6073, 6076, 6078 (2008). A 60 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and the other eye is 20/100; (2) corrected visual acuity of one eye is to 15/200 and the other eye is to 20/100; (3) corrected visual acuity of one eye is to 10/200 and the other eye is to 20/100; (4) corrected visual acuity of one eye is to 5/200 and the other eye is to 20/100; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/100 or 20/70 or 20/100, respectively. 38 C.F.R. § 4.84a, DCs 6065, 6069, 6073, 6076 (2008). A 70 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 20/200 and the other eye is 20/200; (2) corrected visual acuity of one eye is to 15/200 and the other eye is to 20/200; (3) corrected visual acuity of one eye is to 10/200 and the other eye is to 20/200; (4) corrected visual acuity of one eye is to 5/200 and the other eye is to 20/200; or (5) blindness or anatomical loss of one eye and corrected vision in the other eye to 20/200. 38 C.F.R. § 4.84a, DCs 6064, 6068, 6072, 6075 (2008). An 80 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 15/200 and the other eye is 15/100; (2) corrected visual acuity of one eye is to 10/200 and the other eye is to 15/200; (3) corrected visual acuity of one eye is to 5/200 and the other eye is to 15/200; or (4) blindness or anatomical loss of one eye and corrected vision in the other eye to 15/200. 38 C.F.R. § 4.84a, DCs 6064, 6068, 6072, 6075 (2008). A 90 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 10/200 and the other eye is 10/100; (2) corrected visual acuity of one eye is to 5/200 and the other eye is to 10/200; or (3) blindness or anatomical loss of one eye and corrected vision in the other eye to 10/200. 38 C.F.R. § 4.84a, DCs 6064, 6068, 6072, 6075 (2008). A 100 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity of one eye is to 5/200 and the other eye is 5/100; (2) blindness or anatomical loss of one eye and corrected vision in the other eye to 5/200; or (3) blindness or anatomical loss of both eyes. 38 C.F.R. § 4.84a, DCs 6061, 6062, 6063, 6067, 6071 (2008). With respect to impairment of field vision, measurement of the visual field will be made when there is disease of the optic nerve or when otherwise indicated. 38 C.F.R. § 4.76. The method for deriving the measurements contemplated in DC 6080 is set forth in 38 C.F.R. §§ 4.76 and 4.76(a). Computation of average concentric contraction of visual fields is determined by recording the extent of the remaining visual fields in each of the eight 45 degree principal meridians. The number of degrees lost is determined at each meridian by subtracting the remaining degrees from the normal visual fields given in Table III. The degrees lost are then added together to determine total degrees lost. This is subtracted from 500. The difference represents the total remaining degrees of visual field. The difference divided by 8 represents the average contraction for rating purposes. Id. The normal visual field extent at the 8 principal meridians is 85 temporally and down temporally, 65 degrees down, 50 degrees down nasally, 60 degrees nasally, 55 degrees up nasally, 45 degrees up, and 55 degrees up temporally. The total visual field is 500 degrees. 38 C.F.R. § 4.84, Table III. The specific rating criteria underlying DC 6080 show that a concentric contraction of visual field to 60 degrees, but not to 45 degrees, warrants a 20 percent disability rating for bilateral loss, a 10 percent disability rating for unilateral loss, or is rated as 20/50 (6/15) under the visual acuity codes. Bilateral loss of the nasal half of the visual field also warrants a 20 percent disability rating, unilateral warrants a 10 percent disability rating, or is rated as 20/50 (6/15). Bilateral loss of the temporal half of the visual field warrants a 30 percent disability rating, unilateral loss warrants a 10 percent disability rating, or is rated as 20/70 (6/21). 38 C.F.R. § 4.84a. Concentric contraction of visual field to 45 degrees, but not to 30 degrees, warrants a 30 percent if bilateral, a 10 percent if unilateral, or is rated as 20/70 (6/21). Id. Concentric contraction of the visual field to 30 degrees but not to 15 degrees results in a 50 percent evaluation if bilateral, a 10 percent rating if unilateral, or is ratable as 20/100 (6/30). Id. Concentric contraction of visual field to 15 degrees, but not to 5 degrees, warrants a 70 percent if bilateral, a 20 percent if unilateral loss, or is rated as 20/200 (6/60). Id. Concentric contraction of the visual field to 5 degrees results in a 100 percent evaluation if bilateral, a 30 percent rating if unilateral, or is ratable as 5/200(1.5/60). Id. The Board notes that as a general matter combined ratings for disabilities of the same eye should not exceed the amount for total loss of vision of that eye unless there is anatomical loss of the eye or a serious cosmetic defect in addition to the total loss of vision. 38 C.F.R. § 4.80. Turning to the evidence of record, the Board notes that the claims file is extensive, consisting of eight volumes of VA and private outpatient treatment records, examination reports and medical opinions. These records cover a period from 1988 to 2013 and in some cases appear to be multiple duplicates of various documents submitted to VA on numerous occasions in connection with the Veteran's different claims. The Board notes that it has reviewed all of the evidence in the Veteran's claims file and VVA file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, 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 claim. I. Rating in excess of 10 percent from July 5, 1989, to May 13, 1992 During this timeframe, evidence relevant to the severity of the Veteran's service-connected eye disorder includes a December 1988 private treatment report which shows the Veteran's vision with best correction was 20/20 bilaterally. External examination was normal and motility full. The Veteran was orthophoric at distance without correction and had two diopters of exophoria at near. Pupils were round and reactive to light and near. Anterior segment was clear and pressure was 19 on the right and 18 on the left. Cup-disk ratio was .400 and both maculas had marked retinal pigment epithelial changes. There was no evidence of elevation or fresh hemorrhage. Goldmann visual fields showed enlarged blind spots bilaterally. The left visual field appeared to be constricted nasally. The Amsler grids showed marked central and paracentral distortion bilaterally. The diagnoses included macluopathy of unknown etiology, possibly post-vilar encephalitis, refractive error and status post repair of a retinal hole on the right. See Eye Examination report from the State of Maine Department of Human Services, Division of Eye Care and Special Services dated in December 1988. The accompanying Goldman visual field chart reflects findings of concentric contraction of the Veteran's field of vision. The chart (as interpreted by the September 2012 VA consulting specialist) shows an average concentric contraction of the visual field in the Veteran's right eye was to approximately 41 degrees based on a finding of 44 degrees temporally, 46 degrees down temporally, 45 degrees down, 40 degrees down nasally, 43 degrees nasally, 37 up nasally, 32 degrees up, and 40 degrees up temporally. The total remaining visual field for the right eye is 327. When 327 is divided by 8, the result is 40.875. The left eye showed an average contraction to 37 degrees based on findings of 45 degrees temporally, 40 degrees down temporally, 28 degrees down, 37 degrees down nasally, 39 degrees nasally, 36 up nasally, 32 degrees up, and 42 degrees up temporally. The total remaining visual field for the left eye is 299. When this number is divided by the eight directions, rounded up, the average contraction (37.375) is obtained. The visual field of each of the 8 principal meridians in the Veteran's left eye adds up to 299 degrees. When this number is divided by 8, the result is 37.375. Also of record is a September 1989 VA examination report, which shows the Veteran gave a history of some sort of retinal pigmentary disease that required laser treatment in 1977 and had been more or less stable since then. He was apparently seen for laser treatment to the right eye in 1978. His current complaints were of constant double vision, sensitivity to bright light, and that images from the right eye looked larger than those from the left eye. Examination of the optic fundi revealed no retinal abnormalities. Eye movements were full vertically and horizontally. The left eye was slightly up compared to the right in all direction of gaze, however conjugate movement appeared to be normal and the Veteran could converge. Both pupils reacted to light. Examination of the visual fields revealed a fairly large blind spot in the right eye in the superior temporal field and in the left eye in the inferior temporal field. The evaluation did not include the visual acuity for either eye, nor did it include any specific visual field findings. A March 1991 private eye examination shows corrected vision of 20/30-11 on the right and 20/30-1 on the left. The lids and adnexae were clean bilaterally. Extraocular motility was full and intact in both eyes. The conjunctivae were white and quiet bilaterally. The corneas were lustrous and the anterior chambers were deep and quiet. The pupils showed no ADP and lenses were clear. The cup-disk ratio was slightly asymmetrical, left greater than right. It was noted that the visual fields were attached without holes or breaks, but the report does not otherwise contain specific visual field findings. The clinical impression was history of acute multifocal plaquoid posterior epitheliopathy, bilaterally. See clinical records from G.M. Gratwick, M.D. dated in March 1991. Based upon the preceding evidence, the Board finds no basis to grant a disability rating higher than 10 percent for the Veteran's bilateral eye disorder under DC 6075. In order for the Veteran to satisfy the next-higher rating based upon central visual acuity, his corrected vision must be at least 20/50 in one eye and 20/70 in the other eye. See § 4.84a, DC 6078. However, such is not the case. Because the above findings show the visual acuity both eyes is no worse that than 20/30, a 20 percent rating is not warranted for the timeframe in question. See DCs 6077 and 6078. While the loss of central visual acuity does not warrant a higher evaluation, the objective clinical findings do show that the Veteran has been found to exhibit visual field loss consistent with 30 percent evaluation under DC 6080. The results of the December 1988 test, as interpreted by the September 2012 VA consultant, shows the Veteran had approximately 41 degrees of central visual field remaining in his right eye and approximately 37 degrees of central visual field remaining in his left eye. When applying the most restrictive of these calculated values, his visual contraction falls within the range category of 45 degrees, but not to 30 degrees under DC 6080. Within this range, a 30 percent rating is prescribed. The Board recognizes that this code also directs that such a level of disability is ratable as 20/70 visual acuity, bilaterally. This finding, in turn, comports with a 30 percent evaluation under the visual acuity codes. 38 C.F.R. § 4.84a, DC 6078. So, notwithstanding the fact that the Veteran's actual bilateral visual acuity during this rating period has been in the near-normal range -- 20/30-11 in his right eye and 20/30-1 in his left eye - the Board finds that he has satisfied the criteria for a 30 percent rating based on his marked visual field impairment. In reaching this determination, the Board is mindful of the April 2013 VA consultant's observation that while the Veteran's visual fields had decreased in size, there was always the possibility of a hysterical field restriction. He also noted that the Veteran ambulated quite well for such a limited visual field. Nevertheless, the Board considers it significant that the physician did not expressly indicate that the results of the 1988 Goldmann test were inaccurate. Nor has any other VA or private clinician. Accordingly, the Board has no basis to question the reliability of that test as an indicator of the Veteran's visual field impairment. The Board also recognizes that the December 1988 eye examination occurred several months prior to the date upon which the Veteran filed his claim to reopen in July 1989. Nonetheless these findings tend to shed some light on the severity of the Veteran's condition at the time he filed his claim and thus it is highly likely that the Veteran suffered from the same or similar loss of field of vision in July 1989. The evidence fails to show the next-higher rating under impairment of field vision, DC 6080. In order to warrant the next-higher 50 percent rating, the evidence must show concentric contraction of the visual field to 30 degrees but not to 15 degrees bilaterally. The remaining evidence during the period in question includes a September 1989 VA examination report in which the examiner reported that visual fields revealed a fairly large blind spot in the right eye in the superior temporal field and in the left eye in the inferior temporal field. A March 1991 private examination report noted the visual fields were attached without holes or breaks. However neither report contains specific visual field findings. In the absence of a chart showing visual field contraction at each of the eight principal meridians, the examination reports are inadequate for rating purposes. As such, a higher than 30 percent rating based on both impairment of central visual acuity and impairment of field vision is not warranted for the period from July 5, 1989 to May 13, 1992. Resolving all doubt in the Veteran's favor, a 30 percent rating, but no higher, for APMPPE is warranted under DC 6080 from July 5, 1989 to May 13, 1992. Combining the 30 percent evaluation for impaired field vision under DC 6080 with the 10 percent evaluation for continuance of active pathology under DC 6008 yields a combined rating of 40 percent for the Veteran's APMPPE. 38 C.F.R. §§ 4.25, 4.84a, DCs 6008, 6080. II. Rating in excess of 40 percent from May 14, 1992, to July 11, 2002 When examined by VA in May 1992, the Veteran's corrected distant visual acuity was 20/60 in both eyes. A Humphrey visual field test was completed in conjunction with the examination and noted low patient reliability for the right eye. Based on these findings, the RO increased the disability rating evaluation for the Veteran's bilateral eye disorder to 40 percent, effective May 14, 1992. See August 2003 Rating Decision. Although the evidence of record since the May 1992 examination report shows continued treatment of the Veteran for complaints of variable visual acuity with blind spots and double vision, it does not indicate that the disability met the criteria for a rating in excess of 40 percent. For example when examined by VA in February 1996, the Veteran's corrected distant visual acuity in the right eye was 20/40-2 and 20/40+2 in the left eye. Although he reported diplopia at near and distance, the Veteran was orthophoric at distance (eyes are straight) and had exophoria at near. He also had a visual field deficit, which the examiner noted was difficult to interpret. The examination report does not otherwise contain specific Goldmann visual field findings. Also of record is a May 1998 private treatment record for ocular examination and visual fields. At that time the examination the Veteran had visual acuity corrected of 20/70-1 on the right, pinhole no help, and 20/60+, with pinholing improving to 20/50. His intraocular pressure was 17 on each side and he had 1+ nuclear sclerotic cataracts bilaterally. Funduscopic examination found a 0.3 cup disc ratio on each side. His macular area on the right side demonstrated a heavily pigmented laser scar in the macular papular bundle nasal to the fovea. There were mild RPE changes around the fovea, but there was a good foval reflex. Goldmann preimtery was performed which showed the visual fields were full on each side. It was noted that the Veteran had reduced vision in each eye from mild macular degeneration, but seemed to function well. It was noted that in spite of his impairment he was able to perform most tasks. The Goldman visual field chart associated with eye examination reflects (as interpreted by the September 2012 VA consulting specialist) an average contraction of the right eye to approximately 49 degrees based on a finding of 70 degrees temporally, 66 degrees down temporally, 46 degrees down, 44 degrees down nasally, 47 degrees nasally, 45 up nasally, 32 degrees up, and 39 degrees up temporally. The total remaining visual field for the right eye is 389. When this number is divided by 8, the result is 48.625. The left eye showed an average contraction to approximately 48 degrees based on findings of 58 degrees temporally, 64 degrees down temporally, 50 degrees down, 47 degrees down nasally, 43 degrees nasally, 37 up nasally, 34 degrees up, and 52 degrees up temporally. The total remaining visual field for the left eye is 385. When this number is divided by 8, the result is 48.125. Notes from the Ophthalmology Department at Yale University dated in November 1998, show the Veteran's vision was 20/40 in each eye slowly and pin holes about the same. Goldmann field examination showed a significant temporal scotoma on the right and nasal scotoma on the left, but there were no active lesions in the retina. An August 2000 VA examination report revealed visual acuities of 20/30+ on the right and 20/30 on the left with a slight correction. Goldman visual field testing showed mild constriction of both visual fields without any specific abnormalities. However the VA examination report does not contain specific Goldmann visual field findings. With an Amsler grid the Veteran identified several spots in the central region. There were no external abnormalities, although the Veteran was photophobic. Eye movements were normal and full. There were no slit lamp abnormalities. Intraocular pressure were 15 millimeters of mercury on the right and 15 on the left. Dilated funduscopic examination showed normal optic nerves and normal peripheral retinas. However there were pigment epithelial abnormalities in both maculas primarily characterized by some clumping and irregularity. The examiner concluded that with the exception of a slight decrease in visual acuity and minimal loss of visual field, the Veteran's ophthalmic examination was relatively unremarkable. He further concluded that based on the examination there should be minimal disability and that despite some decrease in central vision, the Veteran should be able to pass a standard eye examination for driving. He noted that with regard to the double vision, this could not be explained as there was no evidence of ophthalmoplegia. Also of record is a private medical opinion, which shows the Veteran was seen in July 2001 for follow-up of his multifocal choroiditis and APMPPE. It was noted that at the time of the evaluation the Veteran's vision was 20/70 in both eyes. Slit lamp examination was unchanged. Pressures were measured at 12 and 14. Ophthalmoscopy of the both eyes revealed stable optic nerve head without evidence of active swelling. The appearance of the macula was also unchanged with a relatively large central area of significant pigment dispersion with several small surrounding satellite lesions in the right eye. Similarly there were multiple foci of choroiditis at fixation and scattered elsewhere in the posterior pole in the left eye. Evaluation of the periphery showed a treated superotemporal tear. There was no current evidence of vasculitis, active choroiditis, or vitritis. There were no new holes or tears. A fluorescein angiography showed more extensive retinal pigment epithelial scarring, which appeared old and there was no evidence of leakage. The examiner noted that in response to the Veteran's request he could confidently date it as not having been active in at least the last six months. The medical opinion did not contain specific Goldmann visual field findings. See medical opinion from T.E. Flynn, M.D. dated August 2, 2001. The objective evidence simply does not support the Veteran's contention that his vision has worsened beyond the current 40 percent rating. The above findings show his actual worst visual acuity measurement was 20/70 in both eyes. Table V indicates that a 30 percent rating is the highest rating available to the Veteran based on his current visual acuity measurements. Because the Veteran continued to demonstrate active pathology during this period, the 30 percent is combined with an additional 10 percent, for a combined rating of 40 percent. 38 C.F.R. §§ 4.25, 4.84a, DCs 6008, 6078. In order to satisfy the next-higher rating based upon central visual acuity, his corrected vision must be at least 20/70 in one eye and 20/200 in the other eye. See C.F.R. § 4.84a, DC 6076. The Board's review of the Veteran's VA treatment records fails to show any findings of such severity. Rather because the above findings show an actual visual acuity measurement of no worse than 20/70 in both eyes, a higher rating is not warranted for the timeframe in question. The evidence fails to show the next-higher rating under impairment of field vision, DC 6080. As noted before, in order to warrant the next-higher 50 percent rating, the evidence must show concentric contraction of the visual field to 30 degrees but not to 15 degrees bilaterally. In this case the results of the May 1998 test, as interpreted by the September 2012 VA consultant, shows the Veteran had approximately 49 degrees of central visual field remaining in his right eye and approximately 48 degrees of central visual field remaining in his left eye. When applying the most restrictive of these calculated values, his visual contraction falls within the range category of 60 degrees, but not to 45 degrees under DC 6080. Within this range, a 20 percent rating is prescribed. The Board recognizes that this code also directs that such a level of disability is ratable as 20/50 visual acuity, bilaterally. This finding, in turn, comports with only a 10 percent evaluation under the visual acuity codes. 38 C.F.R. § 4.84a, DC 6078. As such, a higher than 40 percent rating based on both impairment of central visual acuity and impairment of field vision is not warranted for the period from May 14, 1992, to July 11, 2002. III. Rating in excess of 80 percent from July 12, 2002, to March 28, 2003 Finally, the Board comes to the most recent rating period, beginning July 12, 2002. This was the date of a private follow-up examination, which demonstrated visual acuity levels of 20/200, bilaterally. Slit lamp examination was changed expect for a slight increase in the obvious flare in the anterior chamber of both eyes, more notable on the right. The examiner was unable to see any correlation with active inflammatory cells. Pressures were measured at 8 and 7 which was somewhat decreased as compared to previous pressure in early June. Opthalmoscopic evaluation showed no evidence of vitritis. There was a posterior vitreous separation and unchanged optic nerve head with surround nerve fiber layer defects and a central macular scar without obvious activity or exduative complications. The peripheral multifocal choroiditis is also unaltered. Ophthalmoscopy of the left eye also revealed nerve head with surrounding nerve fiber layer defects. There was a central macular scar which is unchanged. The peripheral chorioretinal scars are inactive. The examiner could not rule out a possible small inflammatory episode in the last six weeks although he saw no signs of active inflammation currently. There was no definite treatment that needed to be rendered, beyond monitoring. The remaining records include several private eye examination reports which show that at a one month follow-up, in September 2002, corrected visual acuity was 20/200 in both eyes. Approximately one week later corrected visual acuity was 20/200 on the right and 20/200+1 on the left. In October 2002, the Veteran's corrected visual acuity was 20/200 on the right and 20/100-1 on the left. In December 2002 corrected visual acuity was 20/200 bilaterally. However, by March 28, 2003 the Veteran's corrected visual acuity was 20/400 bilaterally. Based on these findings, the RO increased the disability rating evaluation for the Veteran's bilateral eye disorder to 100 percent, effective March 28, 2003 (10/200 in both eyes, equal to a 90 percent evaluation with an additional 10 percent evaluation added due to continuous active pathology). See August 2003 Rating Decision. The evidence prior to March 28, 2003, shows the Veteran consistently displayed visual acuity levels no worse than 20/200 bilaterally. Table V indicates that a 70 percent rating is the highest rating that is available to the Veteran based on these visual acuity measurements. Because the Veteran continued to demonstrate active pathology during this period, this 70 percent is combined with an additional 10 percent, for a combined rating of 80 percent. 38 C.F.R. §§ 4.25, 4.84a, DCs 6008, 6075. Therefore in order to satisfy the next-higher rating based upon central visual acuity, his corrected vision must be at least 15/200 in each eye or even worse under DC 6075. As the Veteran's visual acuity was not demonstrated to a level worse than 20/200 in either eye during this period, entitlement to a higher evaluation on the basis of impaired visual acuity is not warranted. Moreover, none of the treatment records include measurement of field of vision, thus, the eye disorder cannot be rated under DC 6080 during this period. As such, a higher than 80 percent rating based on both impairment of central visual acuity and impairment of field vision is not warranted for the period from July 12, 2002, to March 28, 2003. IV. Additional (Including Extra-schedular) Considerations and Conclusion The Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1), which stipulate that an extra-schedular rating is in order when there exists such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The schedular evaluations in this case are not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual as to render impractical the application of the regular schedular standards and the Board has been similarly unsuccessful. In this case, the symptoms described by the Veteran and in the clinical records fit squarely within the criteria found in the relevant diagnostic codes (6008, 6061-6079, 6080) used for evaluating eye disorders the rating criteria contemplate not only his symptoms but the severity of the condition, and provide an opportunity for the assignment of a still higher evaluation. Moreover, the evidence does not establish that the disability necessitates frequent periods of hospitalization, and the VA examinations are void of any finding of exceptional symptomatology beyond that contemplated by the schedule of ratings. The Veteran's complaints and demonstrated impairment attributable to his bilateral eye disorder are adequately contemplated by the 40 and 80 percent ratings currently assigned during the appeal period. Accordingly, the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b) (1) are not met. See Bagwell v. Brown, 9Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It is not the Board's intent, in its discussion of the merits of this case, to in any way trivialize the severity of the Veteran's complaints. The Board realizes that he may genuinely believe that the severity of his bilateral eye disorder merits a higher rating, and he is competent to describe readily visible and identifiable symptoms. Full consideration has been given to his assertion that he experiences light sensitivity, distorted vision, and double vision. However, for the reasons stated herein, the Board finds that the criteria for higher rating for this service-connected disability have not been met. Therefore, bearing in mind the benefit of the doubt doctrine, an increased evaluation to 40 percent, but no higher, is granted for APMPPE, from July 5, 1989 to May 13, 1992. The criteria for the assignment of initial disability ratings in excess of 40 percent from May 14, 1992, to July 11, 2002, and in excess of 80 percent from July 12, 2002 to March 27, 2003 are not met. Fenderson, supra. The current levels of disability shown are encompassed by the ratings assigned, and, with due consideration to the provisions of 38 C.F.R. § 4.7, higher evaluations are not warranted for this disability for any portion of the time period under consideration. In other words, there is no basis for the assignment of further staged ratings. ORDER From July 5, 1989 to May 13, 1992, entitlement to a disability rating of 40 percent (but no higher) for APMPPE is granted, subject to the laws and regulations governing payment of monetary benefits. From May 14, 1992, to July 11, 2002 a disability rating in excess of 40 percent for APMPEE is denied. From July 12, 2002 to March 27, 2003 a disability rating in excess of 80 percent for APMPEE is denied. REMAND Residuals of Cryptococcus Neoformans Infection The Veteran contends that his service-connected Cryptococcus neoformans infection residuals are more disabling than reflected in the current 10 percent disability rating. By way of background, the grant of service connection was based upon an in-service lab test revealing a positive cryptococcal antigen and a November 2000 MRI report showing a tiny, non-specific focus of increased FLAIR signal within the left occipitoparietal lobe that have been linked to the Cryptococcus neoformans infection in service. Currently this disability is rated by analogy under DC 8019 for cerebrospinal meningitis, which provides for a 100 percent evaluation when the disease is active. Otherwise, residuals are to be rated separately, with any residuals identified receiving a minimum 10 percent evaluation. 38 C.F.R. § 4.124a. Crucially, Note (1) under this section specifies that it is required for the minimum ratings for residuals under diagnostic codes 8000-8025 that there be "ascertainable residuals." A determination as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the diseases and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses. See 38 C.F.R. § 4.24a, Note (1). The Board notes that the Veteran has recently argued that his Cryptococcus neoformans infection residuals should be rated as a parasitic disease, not otherwise specified under 38 C.F.R. § 4.88b, DC 6320. This diagnostic code likewise provides for the assignment of a 100 percent evaluation for active disease; thereafter, residuals, such as spleen or liver damage are rated under the appropriate system. The Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). (Parenthetically, the Board notes that the rating criteria employed under DC 6320 are essentially identical to those employed under DC 8019.) That said, the Board has attempted to determine whether the Veteran in fact has "ascertainable residuals" of Cryptococcus neoformans infection that may be separately compensated pursuant to the provisions noted above. As noted in the Introduction, this case was previously before the Board in August 2012. At that time the Board issued remand directives that instructed the AMC/RO to schedule the Veteran for an appropriate examination to determine whether he has any additional residuals of the Cryptococcus neoformans infection and, if so, their current level of severity. The examiner was specifically asked to discuss the pathology of the Veteran's Cryptococcus neoformans infection and whether it is analogous to an active parasitic disease. The examiner was also asked, to the extent possible, to distinguish symptoms of Cryptococcus neoformans infection versus his diagnosed bilateral APMPPE. The record indicates that the Veteran was afforded a VA examination in September 2012, in which the examiner concluded that based on a titer of 1:1, which was not considered significant for a diagnosis of the disease or even a past infection, the Veteran did not ever have a Cryptococcus neoformans infection. The AMC/RO later sought additional insight into the Veteran's condition and a clarification opinion was provided by a VA physician in June 2013. At that time the VA physician noted that the Veteran's systemic inflammatory process was presumed to be secondary to a Cryptococcus neoformans infection, however the supporting evidence for the Veteran ever having such an infection was limited to a positive titer in 1977. The physician, at any rate, went on to conclude that that there was no indication of current active infection with Cryptococcus neoformans and that the Veteran's central nervous system residuals (headaches) were stable. Citing to specific medical literature, the physician then concluded that Cryptococcus was not a parasitic infection, but rather was a fungus. Unfortunately, the VA opinion is not entirely responsive to the Remand order and is inadequate for rating purposes. Hayes v. Brown, 9 Vet. App. 67, 73 (1996). Once VA undertakes the effort to provide an examination when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Although the physician determined that the Veteran had current CNS residuals (headaches), he did not otherwise indicate their current severity. As a result, this case presents certain medical questions which cannot be answered by the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) [the Board is prohibited from exercising its own independent judgment to resolve medical questions]. These questions concern the current nature of the Veteran's service-connected residuals of Cryptococcus neoformans infection affecting the central nervous system, to include whether such disability manifests in headache residuals that may be separately compensated. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) [a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim]. Thus, a remand is necessary to afford the Veteran another VA examination. The remand will also allow for original consideration of the additional evidence that has been added to the claims file it was last readjudicated by the Agency of Original Jurisdiction. See 38 C.F.R. §§ 19.37, 20.1304. Finally, the Board observes that the Veteran is appealing the original assignment of the disability rating for his service-connected Cryptococcus neoformans infection and central nervous system residuals following the award of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings-that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Thus, the disability evaluation must be considered from July 5, 1989 to the present. TDIU With respect to the TDIU claim, as noted in the Introduction, the RO granted a TDIU, effective from July 12, 2002 (the effective date of the 80 percent rating for APMPPE). Although the Board granted an increased staged rating for the bilateral eye disorder in this decision, the evaluation is still less than a full 100 percent grant and the Veteran does not presently meet the schedular requirements for TDIU under 38 C.F.R. § 4.16(a). He has also presented some evidence that he was unemployable due to his service-connected bilateral eye disorder prior to July 12, 2002. Accordingly, the Veteran's TDIU claim should be referred to VA's Director of Compensation and Pension Service for extraschedular consideration of TDIU under 38 C.F.R. § 4.16(b), for the period prior to July 12, 2002. Accordingly, the case is REMANDED for the following action: 1. After obtaining the appropriate release of information forms from the Veteran, procure any medical records not already in the claims file relating to recent treatment for, or evaluation of, his service-connected Cryptococcus neoformans infection residuals, specifically to include headaches. All pertinent records should be obtained and associated with the claims folder. Document the attempts to obtain such records. If the AMC/RO is unable to obtain any pertinent evidence identified by the Veteran, so inform him and request that he obtain and submit it. If any records are unavailable, do not exist, or further attempts to obtain them would be futile, document this fact in the claims file. See 38 U.S.C.A. § 5103A(b). 2. Then, accord the Veteran a VA examination to determine severity and manifestations of his service-connected Cryptococcus neoformans infection residuals, manifested as headaches. The claims folder must be made available to the examiner for review, and the examination report should include discussion of the Veteran's documented medical history and assertions. A notation to the effect that this record review took place should be included in the report. All indicated tests and studies should be performed, and the examiner should review the results of any testing prior to completing the report. The examiner should describe all pertinent symptomatology and findings associated with the Veteran's service-connected Cryptococcus neoformans infection residuals, manifested as headaches. After the examiner obtains from the Veteran information regarding the frequency, severity and duration of his migraines, he/she should express an opinion as to whether the headaches are very frequent, completely prostrating, or prolonged and whether the headaches are productive of severe economic inadaptability. Additionally, the examiner should also review pertinent aspects of the Veteran's medical and employment history, and comment on the effects of the headaches upon his ordinary activity and the effect that the headaches have, if any, on the Veteran's current level of occupational impairment. The conclusions of the examiner should reflect review of the claims folder, and the discussion of pertinent evidence. 3. After completing the requested action, and any additional notification and/or development deemed warranted, readjudicate the increased rating claim on appeal. In addition pursuant to 38 C.F.R. § 4.16(b), refer the TDIU claim to VA's Director of Compensation and Pension Service for extraschedular consideration as to whether the Veteran was unemployable due to service-connected disability prior to July 12, 2002. 4. Unless the benefits sought on appeal are granted, the Veteran and his representative should be furnished a supplemental statement of the case, to include information regarding why the Veteran failed to meet the requirements for an extraschedular evaluation, and afforded an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. See 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 or by the Court 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. R. FLETCHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs