Citation Nr: 1333622 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 01-07 090 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a left eye cataract, secondary to Thorazine medication used to treat a service connected psychosis not otherwise specified. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from November 1968 to August 1969. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama which denied entitlement to service connection for complication of eyes. Entitlement to service connection for cortical cataracts of the right eye was granted in March 2011. That issue is therefore no longer before the Board, leaving the issue of entitlement to service connection for a left eye cataract as the sole remaining issue before the Board on this appeal, as indicated on the title page. Although the Veteran requested a hearing before the Board in his August 2008 substantive appeal, he withdrew that request in December 2008. The request for a hearing is thus considered withdrawn. 38 C.F.R. § 20.704 (2013). The Board notes that the Veteran testified before the undersigned at a Board hearing in February 2002 that pertained to issues not on appeal herein. In July 2011 and February 2013, the Board remanded the claim to the RO, via the Appeals Management Center (AMC) for additional development. FINDING OF FACT The evidence is evenly balanced as to whether a left eye cataract is related to Thorazine medication used to treat a service connected psychosis not otherwise specified. CONCLUSION OF LAW A left eye cataract is proximately due to or the result of medication taken for service connected psychiatric disease. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). As the Board is, however, granting the only claim being decided herein, further discussion of the VCAA is unnecessary. Wensch v. Principi, 15 Vet. App. 362, 367-368 (2001). The Veteran contends that his left eye disorder, which has been diagnosed as a cataract, is related either Thorazine medication used to treat a psychosis not otherwise specified, or to his service connected diabetes. While entitlement to service connection is warranted for disability due to disease or injury in service, service connection is also warranted for disability that is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). As the Board finds that the Veteran's left eye cataract is proximately due to or the result of Thorazine medication consideration of the other theories of entitlement is unnecessary. The Veteran is service connected for cortical cataracts of the right eye. The Veteran has also been diagnosed with a cataract of the left eye and claims that service connection is also warranted for this disorder. The October 2009 VA eye examination report upon which the RO relied to award service connection for a right eye cataract did not identify or address any left eye pathology. Thus, the Board remanded this issue in July 2011 for the purpose of obtaining a medical opinion regarding whether a left eye cataract is related to either diabetes and/or military service. Since that time, there have been medical opinions offered as to whether the Veteran's left eye cataract is related to Thorazine. A January 2012 VA Disability Benefits Questionnaire (DBQ) examination report reflects a history of right eye trauma in the 1970s, Thorazine use in the 1970s and 1980s, and a diagnosis of a right eye cataract by VA in 1999. The assessment was bilateral cataracts. Regarding the etiology, the author (optometrist N.W.) stated that while diabetes can exacerbate cataract formation, the evidence in this case indicated the Veteran's right eye cataract was more consistent with lens changes commonly seen after a traumatic event. As for the left eye, N.W. opined that these cataracts were due to mild age-related changes. Notably, it does not appear that N.W. conducted the Veteran's eye examination. In this regard, the claims file contains an optometry note dated the same day as the VA DBQ examination that was completed by a different optometrist, L.S., and co-signed by N.W. L.S.'s assessment was that the Veteran has bilateral cataracts due to normal age-related changes and Thorazine use. In an addendum to L.S.'s report, N.W. indicates disagreement as to Thorazine use as a possible etiology. Specifically, he stated that the asymmetry between the right and left eye argued against either diabetes or Thorazine use as an etiology. Following the January 2012 VA examination, the AMC returned the Veteran's claims file to N.W. for an addendum. In a June 26, 2012, report N.W. opined that the Veteran's left eye cataract was neither due to active military service nor due to diabetes mellitus (to include the question of aggravation). In this regard, N.W. explained that cataracts could not be related to service absent some indication of left eye trauma during service. N.W. then explained that the most common type of cataract is nuclear sclerotic, that this is what the Veteran has, and that this type of cataract is due to age-related changes. Although the opinion provided by N.W. appears to have been based upon a review of the January 2012 examination as well as the claims file, it was not clear whether all pertinent evidence of record was considered and/or adequately discussed. As noted by the Board, service and post service treatment records reflect Thorazine use for the Veteran's service connected psychosis, not otherwise specified and there are multiple diagnoses of Thorazine-related cataracts. For example, L.S. indicated in a January 2012 VA annual optometry examination report that there was a Thorazine cataract with spoking pattern, right eye greater than left. L.S. diagnosed normal age related changes of both eyes and "the classic Thorazine cataract" of both eyes, right greater than left. In a February 2011 VA treatment note, a VA optometrist wrote, "Thorazine cataract OD; mild OU," which appears to reflect Thorazine cataracts of both eyes. Given the conflicting evidence above, the Board instructed that the Veteran be afforded a new VA examination and one was conducted in April 2013. The examiner did not, however, address the left eye cataracts. The only diagnosis pertained to the right eye and the prior trauma. An addendum was sought, but the only addendum in the physical or Virtual VA claims file was that of a VA psychiatrist. He concluded that the cataracts were not likely related to the Thorazine because the appellant was treated only briefly for his psychiatric disorder in service it was not clear whether the treatment was with Thorazine and, even if it was, the duration of the treatment, the numerous other possible causes of cataracts, and the interval from that treatment to onset of cataracts would make it less likely than not that cataracts were the cause of the cataracts. Initially, the Board in its February 2012 remand instructed that the examination was to be performed by an ophthalmologist. The April 2013 examination, however, was by an optometrist and the May 2013 addendum was by a psychiatrist. In any event, the psychiatrist's opinion was flawed because he appeared to focus on the treatment in service including the interval between such treatment and the onset of cataracts. The psychiatrist's opinion did not address whether the post service Thorazine use either caused or aggravated a left eye cataract. The Board is thus left with the diagnoses of Thorazine-related cataracts as well as the contrary opinions of N.W. and the VA psychiatrist in May 2013. At this point, a remand for yet another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Although the diagnoses of Thorazine-related cataracts did not contain extensive reasoning, they were made by qualified health care professionals based on examination findings and are therefore entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The evidence is thus approximately evenly balanced as to whether the Veteran's left eye cataract is proximately due to or the result of Thorazine taken for service connected psychosis. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a left eye cataract is warranted. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a left eye cataract, secondary to Thorazine medication used to treat a psychosis not otherwise specified is granted. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs