Citation Nr: 1334301 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 12-11 286 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for malignant melanoma of the ciliary body of the left eye, claimed as due to herbicide exposure. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from April 1969 to November 1970. This case comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the RO in Milwaukee, Wisconsin that in pertinent part, denied service connection for malignant melanoma of the ciliary body of the left eye. The record reflects that he has not requested a personal hearing with respect to this appeal. In a July 2013 rating decision, the RO granted service connection for bilateral hearing loss (rated 0 percent disabling), and for tinnitus (rated 10 percent disabling). Since the Veteran did not appeal the ratings or effective dates assigned for these disabilities, these claims are not in dispute. See 38 U.S.C.A. § 7105; Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (indicating he must separately appeal for a higher rating and earlier effective date since these are "downstream" issues from his initial claim for service connection). FINDINGS OF FACT 1. The evidence confirms that the Veteran had service in the Republic of Vietnam during the Vietnam era. 2. The preponderance of the competent and credible evidence does not show that the Veteran's malignant melanoma of the ciliary body of the left eye manifested during a period of active duty service. Nor does the evidence show that this disease was presumptively incurred during a period of active duty or that it is otherwise related to service or any aspect therein. CONCLUSION OF LAW Malignant melanoma of the ciliary body of the left eye was not incurred in or aggravated by the Veteran's military service, nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record: (1) that is necessary to substantiate this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, a letter dated in March 2010 was sent to the Veteran prior to the June 2010 rating decisions on appeal, i.e., in the preferred sequence. This letter informed him of the type of information and evidence required to substantiate the claim for service connection, and advised him of the downstream disability rating and effective date elements of the claim. See Dingess/Hartman, supra. The Board finds that the Veteran has received all required VCAA notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and, moreover, above and beyond this, that it is unduly prejudicial - meaning outcome determinative of his claim. Thus, absent this pleading or showing, the duty to notify has been satisfied. VA also fulfilled its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO obtained his service treatment records (STRs), private medical records, and VA outpatient treatment records. The RO has also considered the Veteran's lay statements and other evidence he submitted in support of his appeal. The Board acknowledges that, to date, the Veteran has not been afforded a VA examination in regard to his claim for service connection. In determining whether the duty to assist requires that a VA examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, no examination is necessary in order to adjudicate the Veteran's claim of entitlement to service connection. Specifically, there is no indication, besides the Veteran's own statements, that his asserted malignant melanoma of the ciliary body of the left eye may be related to his active service, to include herbicide exposure. While the Veteran has been diagnosed with the asserted condition, there is no evidence of such in service or for many years thereafter, there is no evidence of manifestation of the conditions during any applicable presumptive period, and there is no medical evidence of a nexus relating the asserted conditions to service. As such, the necessity for a VA examination has not been triggered. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled, and no further action is necessary under the mandates of the VCAA. Analysis The Veteran contends that his previously diagnosed malignant melanoma of the ciliary body of the left eye was caused by herbicide exposure during service in the U.S. Army in Vietnam, during the Vietnam era. The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA compensation may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Certain diseases, including malignant tumors, are considered chronic, per se, and therefore will be presumed to have been incurred in or aggravated by service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). If a Veteran was exposed to a herbicide agent (including Agent Orange) during active military, naval, or air service, certain specified diseases shall be presumptively service connected, if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service. 38 C.F.R. § 3.309(e). These diseases shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.308(a)(6)(ii). These diseases are chloracne or other acneform disease consistent with chloracne, Type II (adult-onset) Diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, Parkinson's disease, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), AL amyloidosis, and soft-tissue sarcoma. 38 C.F.R. § 3.309(e) (2012). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. If chronicity (i.e., permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Establishing continuity of symptomatology under 38 C.F.R. § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to establish chronicity (permanency) of disease or injury in service and, in turn, link the currently claimed disability to service. See also Clyburn v. West, 12 Vet. App. 296, 302 (1999). The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.307(a)(6), a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, is presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id.; see also 38 C.F.R. § 3.313(a); Haas v. Peake, 525 F.3d 1168, 1197 (Fed. Cir. 2008), cert. denied, 129 S. Ct. 1002 (2009) (upholding VA's interpretation of section 3.307(a)(6)(iii) as requiring the servicemember's presence at some point on the landmass or the inland waters of Vietnam). Thus, service connection may be presumed for residuals of Agent Orange exposure by satisfying two requirements. First, a Veteran must show that he served in the Republic of Vietnam during the Vietnam War era or elsewhere outside of Vietnam where Agent Orange was used or sprayed. See 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must have a diagnosis of one of the specific diseases listed in 38 C.F.R. § 3.309(e). See Brock v. Brown, 10 Vet. App. 155, 162 (1997). However, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing entitlement to service connection with proof of direct causation linking his claimed disability to his military service. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999) (indicating the principles set forth in Combee, which, instead, concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, lay persons are competent to provide opinions on some medical issues; their competency depends entirely on the specific disability at issue. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Specifically, lay evidence has been found to be competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr, supra; see also Jandreau, supra; Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, laypersons also have been found not competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Turning now to the facts of this particular case. Here, private medical records reflect diagnosis and treatment for malignant melanoma of the ciliary body of the left eye in 2006 and afterward, and he has had subsequent residuals. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed and that, without this proof of current disability, there can be no valid claim); see also McClain, supra. So resolution of his appeal, instead, turns on whether malignant melanoma of the ciliary body of the left eye, including any residuals, is attributable to his military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). A review of the Veteran's DD Form 214 shows that he served in the U.S. Army from April 1969 to November 1970, including service in the Republic of Vietnam from October 1969 to November 1970. He received the Vietnam Service Medal and Vietnam Campaign Medal, and his military occupational specialty was chaplain's assistant. The Board notes that malignant melanoma of the ciliary body of the left eye is not a condition subject to presumptive service connection based on herbicide exposure under 38 C.F.R. § 3.309(e). However, this does not prevent the Veteran from establishing service connection on a direct basis. STRs are entirely negative for malignant melanoma of the left eye, and his eyes were clinically normal on separation medical examination in November 1970. A private medical record from Dr. L. dated in May 2004 reflects that the Veteran was a new patient. He gave a history of gout, and complained of foot pain. He did not complain of an eye condition. On examination, his eyes appeared normal. Private medical records reflect that in March 2006, he was seen by an ophthalmologist, Dr. O., who stated that the Veteran was referred for consultation regarding a lesion of the left eye. The physician stated that the Veteran was visually asymptomatic, and had excellent central vision. The Veteran reportedly broke his glasses, and had an eye examination by an optometrist, who observed a mass lesion of his iris. Dr. O. noted that the Veteran smoked two cigars daily for 30 years. He indicated that the Veteran had a vascularized amelanotic lesion of the chamber angle in the left eye, involving the ciliary body. He opined that ciliary body melanoma was the leading candidate in the differential diagnosis. By a letter dated in March 2006, Dr. R. stated that prior to the recent examinations, the Veteran's last ocular examination was two years ago, at which time no abnormalities were seen on examination. He recently broke his glasses, and was seen for an evaluation, at which time his lesion was noted. He currently denied visual changes, but during the recent optometrist's examination, diplopia was noted in the left eye. The Veteran said he had no abnormal moles, and there was no history of melanoma in his family, although his father had been seen for a lesion thought to be basal cell carcinoma or squamous cell carcinoma. The diagnostic impression was amelanotic ciliary body melanoma. Subsequent private medical records reflect that in April 2006, he underwent radiation plaque placement in the left eye to treat the ciliary body melanoma of the left eye, and he thereafter complained of blurred vision in the left eye. Dr. O. stated in August 2006 that his visual symptoms were likely related to radiation-induced lens change. In April 2007, Dr. O. stated that the Veteran's tumor had not grown in a year, but the lesion was still present. He recommended continued observation. He also diagnosed a progressive cataract of the left eye. In August 2007 he stated that the lesion was smaller. Subsequent treatment records from the Veteran's oncologist, Dr. D., showed no evidence of metastatic disease and no evidence of disease recurrence. In multiple statements submitted in support of his claim, the Veteran contended that his malignant melanoma of the ciliary body of the left eye was due to Agent Orange (herbicide) exposure in service. In March 2010, he asserted that ciliary melanoma is a very rare disease, and that chemical exposure could play a role in the development of this disease. He said he was exposed to Agent Orange during service in Vietnam and he had no other significant chemical exposure in his lifetime. He enclosed printouts regarding ciliary body melanoma from various internet sites. A printout from WebMD stated that melanoma of the uveal tract (iris, ciliary body, and choroid), though rare, is the most common primary intraocular malignancy in adults. The printout also stated that several factors likely play a role in the development of uveal melanoma. Host characteristics, such as light pigmentation (skin, hair and eye color) and genetic factors, as well as environmental exposures (sunlight and chemical) have been associated with increased risk in some studies. The Board observes that none of the submitted printouts mention Agent Orange or herbicides. In an April 2012 affidavit, the Veteran reiterated many of his assertions, and asserted that he was exposed to Agent Orange during service, and said there was an unusual lack of cancer in his family. He asserted that a 2004 news report stated that Vietnam Veterans had "an elevated risk of melanoma, the deadliest form of skin cancer." He said that there was a lack of scientific data due to the rare nature of his disease, and that reasonable doubt should be resolved in his favor. As noted above, service connection is not warranted under the presumptions pertaining to herbicide exposure, as malignant melanoma of the ciliary body of the left eye is not a condition subject to presumptive service connection based on herbicide exposure under 38 C.F.R. § 3.309(e). The other potential presumption available is also not applicable in this case since his malignant melanoma of the ciliary body of the left eye was not diagnosed or manifested to a compensable degree during the one-year presumptive period following his separation from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Instead, as discussed above, his malignant melanoma of the ciliary body of the left eye was not diagnosed until 26 years after he had separated from military service. The evidence, including the medical evidence and Veteran's own statements, also reflects that he did not have any symptoms from malignant melanoma of the ciliary body of the left eye until 2006, and the disease was first noted when he went to an optometrist to get new glasses. The Board therefore may consider the absence of any indication of a relevant medical complaint until so relatively long after service as one factor in determining whether a disease in service resulted in chronic or persistent residual disability. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See also Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology following the conclusion of his service and had failed to account for the lengthy time period for which there was no clinical documentation of the claimed disorder). Here, even once diagnosed, there is no competent and credible evidence relating his malignant melanoma of the ciliary body of the left eye to his military service, including the in-service exposure to herbicides. Although the Board must deny service connection for malignant melanoma of the ciliary body of the left eye on a presumptive basis, the Veteran may prove service connection directly. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). But as there is no evidence in his STRs suggesting he had malignant melanoma of the ciliary body of the left eye during or immediately after his service, including during the one-year presumptive period following the conclusion of his service, there is no basis for concluding this condition was directly incurred in service. Indeed, the record indicates he did not have a diagnosis of malignant melanoma of the ciliary body of the left eye until 2006, so the Board finds that the evidence preponderates against a finding that his malignant melanoma of the ciliary body of the left eye began during his service or was aggravated by his service. The Board notes that the Veteran has submitted various internet articles in an attempt to establish a medical nexus between his service and his malignant melanoma of the ciliary body of the left eye. This evidence does not indicate such a link. Moreover, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise "is too general and inclusive." Sacks v. West, 11 Vet. App. 314, 317 (1998) (holding that a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). Still, medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999). See also Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). Here, though, there is no such supporting competent medical opinion, let alone relying on or agreeing with the submitted medical literature to etiologically link the Veteran's malignant melanoma of the ciliary body of the left eye to his herbicide exposure in service. The Board recognizes that the Veteran asserts that his malignant melanoma of the ciliary body of the left eye was caused by herbicide exposure in service. In some cases, such lay evidence is competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Malignant melanoma of the ciliary body of the left eye, however, is a medically complex condition, not readily amenable to lay diagnosis, because it cannot be substantiated by mere lay observation or opinion. See Barr, 21 Vet. App. at 307. It follows, as an unfortunate consequence, that the Veteran is only competent to report experiencing certain symptoms which are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994) (holding that competent testimony is limited to that which the witness has actually observed, and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses, that which is heard, felt, seen, smelled or tasted). He is not similarly competent to render an opinion as to the etiology of his malignant melanoma of the ciliary body of the left eye, or to state whether or not it is attributable to his active service. Moreover, as the Veteran has not been shown to have the requisite clinical training to etiologically relate his malignant melanoma of the ciliary body of the left eye to service, there is no need to assess the credibility of his lay assertions in this regard. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability, including during service and since, even where not corroborated by contemporaneous medical evidence such as treatment records, but also indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). For these reasons and bases, the Board finds that the preponderance of the evidence is against this claim for service connection for malignant melanoma of the ciliary body of the left eye, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Service connection for malignant melanoma of the ciliary body of the left eye is denied. ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs