Citation Nr: 1334562 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-30 092 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial rating higher than 10 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of a left eye injury. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from November 2003 to December 2007. He appealed to the Board of Veterans' Appeals (Board/BVA) from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which granted service connection for PTSD and assigned a 10 percent initial rating for this disability retroactively effective from December 10, 2007, so back to the day after his military service ended when he returned to life as a civilian. He wants a higher initial rating for this disability. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals an initial rating, VA must consider whether to "stage" the rating - meaning assign different ratings at different times since the effective date of the award to compensate him for times when the disability has been more severe than at others). He also appealed the RO's denial of his claim of entitlement to service connection for a left eye condition, including especially for posterior vitreous detachment. The RO denied numerous other claims, as well. In response to the Veteran's September 2009 notice of disagreement (NOD), the RO sent him a June 2010 statement of the case (SOC) continuing to deny these other claims. However, in his March 2010 substantive appeal (on VA Form 9), he clarified that the only claims he still wanted to appeal were those concerning his PTSD and left eye injury. Therefore, he only completed the steps necessary to perfect his appeal of these two claims, meaning they are the only two claims currently before the Board. See 38 C.F.R. §§ 20.200, 20.202, 20.302, etc. (2013). The additional issue of entitlement to service connection for residuals of a traumatic brain injury (TBI) has been raised by the record, however, specifically in VA treatment records showing reports by the Veteran of having been around explosive blasts in service, as well as a diagnosis of post-concussion syndrome. But as the Agency of Original Jurisdiction (AOJ), the RO has not had opportunity to consider this additional claim, so the Board does not have jurisdiction over it at the moment and, therefore, is referring it to the RO for appropriate development and consideration. As for the claims that are as mentioned before the Board, the claim of entitlement to service connection for residuals of a left eye injury requires further development before being decided on appeal, so the Board is remanding this claim to the RO via the Appeals Management Center (AMC) in Washington, D.C. Whereas the Board, instead, is going ahead and deciding the claim for a higher initial rating for the PTSD. FINDING OF FACT The Veteran's PTSD is manifested by a flattened or constricted affect, rapid or pressured speech, memory impairment, flashbacks, sleep disturbances, and Global Assessment of Functioning (GAF) scores primarily of 55 and below. More severe symptoms, such as suicidal ideation, obsessional rituals, near-continuous panic or depression, and spatial disorientation have not been demonstrated. CONCLUSION OF LAW The criteria are met for a higher initial rating of 50 percent for the PTSD, though no greater rating. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) A. Duty to Notify The VCAA was signed into law in November 2000 and enhanced VA's obligations in terms of notifying and assisting claimants with claims for VA benefits. The VCAA was codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126, and the implementing VA regulations were codified as amended at 38 C.F.R. §§ 3.102, 3.156 a, 3.159, 3.326. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, also apprise him of the information and evidence VA will obtain versus the information and evidence he is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). When the claim is for service connection, this notice should address all elements of the claim, including the "downstream" disability rating and effective date elements in the event there is a favorable disposition of the claim. See Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Also, ideally, this notice should be provided before initially adjudicating the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - including in an SOC or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, and the Veteran is given ample 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). The U.S. Supreme Court has made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran has this burden of proof of not only establishing error but also, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of his claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). This particular Veteran is challenging the initial evaluation assigned following the granting of service connection for his PTSD. In Dingess, the U.S. Court of Appeals for Veterans Claims (Court/CAVC) held that in cases where service connection has been granted and an initial disability rating and effective date assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id., at 490-91. Thereafter, once an NOD has been filed contesting a "downstream" issue such as the initial rating assigned for the disability, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 regarding a rating decision and SOC control as to any further communications with the appellant, including as to what evidence is necessary to establish a more favorable decision with respect to the downstream element of the claim. See Goodwin v. Peake, 22 Vet. App. 128 (2008). Therefore, in accordance with 38 U.S.C.A. §§ 5103(a) and 7105(d), the RO provided the Veteran this required SOC in June 2010 citing the applicable rating criteria and containing discussion of the reasons and bases for not assigning a higher initial rating for his disability. He therefore has received all required notice concerning this claim. B. Duty to Assist This additional duty includes assistance in obtaining potentially relevant records, such as service treatment records (STRs) and post-service VA and private medical evaluation and treatment records, as well as the provision of an examination - including for a medical opinion - when necessary to make a decision on the claim. To this end, the Veteran's STRs, VA treatment records, and lay statements have been associated with the claims file. He was also afforded a VA examination. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination obtained in this case is adequate as it is predicated on a review of the claims file, contains a description of the history of the disability at issue, documents and considers the relevant medical facts and principles, and records the relevant findings for rating this disability in relation to the applicable rating criteria. Although the VA examination was in December 2008, the Veteran has not specifically asserted that his disability has worsened appreciably since that examination, and the mere passage of time alone is not a basis for requesting a new examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Therefore, VA's duty to assist with respect to obtaining a VA examination or opinion concerning this disability has been met. 38 C.F.R. § 3.159(c)(4). VA has provided the Veteran opportunity to submit evidence and argument in support of his claim. He has not made the Board aware of any additional evidence needing to be obtained prior to appellate review of this claim, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Rating A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). All reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). Where entitlement to compensation already has been established and increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But as already alluded to, when, as here, the Veteran has appealed the rating assigned for his disability just after establishing his entitlement to service connection for it, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged" rating. See Fenderson, 12 Vet. App at 125-26. The Court also has extended this practice even to claims that do not involve initial ratings, rather, also established ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Veteran is currently assigned a 10 percent rating under Diagnostic Code 9411. A higher 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran's own occupation or name. Id. The record also contains GAF scores. As described in the Fourth Edition of the American Psychiatric Association's DIAGNOSTIC AND STASTICAL MANUAL FOR MENTAL DISORDERS (DSM-IV), GAF scores range from 1 to 100, depending on the level of a person's occupational and social functioning. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; instead, the percentage evaluation is to be based on all the evidence bearing on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. The higher the GAF score, the higher the overall functioning of the individual is. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV, at 32; Richard, 9 Vet. App. at 267. When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). B. Evidence In April 2008, the Veteran reported severe insomnia. He also described disturbing experiences involving memory, where he walks away from a task and later feels surprised to discover what he has or has not done. One example was leaving the shower running without taking a shower. He denied any suicidal ideation or assaultive behavior. He did experience hypervigilance, occasional startle reactions, intolerance to high pitched noises, discomfort in crowds, emotional numbness or disconnect, and intrusive thoughts. He had difficulty with concentration and memory. He preferred to keep his war traumas and events to himself. He was unaware of how much he had changed as a person, but it was obvious to those who knew him before service. His judgment, insight, and recent and remote memory were good on examination, and he was fully oriented. His GAF score was 40. Additional records from May 2008 reflect similar reports, and a GAF score of 45. A separate entry from May 2008 also noted irritability and guardedness. The Veteran's speech and motor activity were normal. His affect was moderately blunted and his mood was mildly anxious and depressed. He reported auditory hallucinations that had unclear content. There was no indication of delusions or a thought disorder. Judgment and insight were fair to poor. He denied any suicidal or homicidal ideation. His GAF score was 35. VA records dated July 2008 show the Veteran reported being more at ease and more engagable. He stated that his sleep problems and PTSD were still present, but that he was "dealing OK with them." Additional records dated September 2008 show the Veteran's mood was mildly depressed. His affect, attire, and hygiene were appropriate. His speech was clear but somewhat pressured. He complained of a lack of sleep and vivid nightmares. He also had problems with memory, including forgetting why he went to a particular location after he arrived there. The Veteran underwent a VA examination in December 2008. He reported that his family and friends noticed a difference in him since he had returned from service, including mood swings and being more agitated and "jumpy." He stated that his family also noted that he seemed "disconnected" at times. The Veteran reported nightmares every night, as well as 10 to 15 flashbacks during the week. He avoided bright lights, flashbulbs, burning odors, and physical contact. He also experienced a loss of energy. He complained of memory loss, and had been involved in 3 or 4 physical altercations since returning home. He had some loss of appetite. He denied any panic attacks, or suicidal or homicidal ideation. He stated that some noises triggered other noises "that weren't there." He also had visual hallucinations of Marines or other people once a week. On examination, the Veteran's affect was somewhat constricted but appropriate. Thought processes were normal. He was unable to complete serial 7's or spell a word backwards. He stated that his mood was usually "pretty good" but sometimes blunted. His GAF score was 65. In September 2009, the Veteran continued to report nightmares, flashbacks, hypervigilance, and general anxiety. On examination, he was watchful and defensive at first, but otherwise alert and oriented. His behavior and speech were unremarkable. There was no evidence of a thought disorder, and no impairment of cognitive function. His mood was euthymic, and his affect was well-modulated. He denied any suicidal or aggressive tendencies. His GAF score was 50. Records from October 2009 show similar findings. The Veteran also reported that he experienced flashbacks triggered by sudden noises. In March 2010, he reported that daytime flashbacks and nightmares had become more intrusive. In April 2010, the Veteran was referred for psychiatric evaluation after sustaining a stab wound to his backside during intoxicated horseplay with a friend. He was referred for evaluation due to his cavalier attitude toward his injury and the professed normalcy of such behavior. On examination, he came across as hypomanic, though he was in no psychological distress. He admitted to anxiety over flashbacks and recurrent memories, but denied any depression, psychotic symptoms, or suicidal or homicidal ideation. He admitted to drinking heavily 2 to 3 days per week. On examination, the Veteran's speech was accelerated. His mood was anxious, and his affect was supple. His GAF score was 55. On examination in May 2010, the Veteran's behavior was mildly agitated and his speech was rapid and pressured. There was no evidence of a thought disorder or psychotic symptoms. His mood was euthymic and his affect well-modulated. He denied any suicidal or aggressive tendencies. His GAF score was 50. C. Analysis Based on the totality of the evidence, the Board finds that a considerably higher initial rating of 50 percent is warranted for the Veteran's PTSD. Throughout the appeal period, meaning since the filing of his claim, his PTSD has been manifested by symptoms such as memory impairment, depressed mood, constricted affect, speech abnormalities, and sleep disturbances. His judgment also was noted to be fair to poor in May 2008. He indicated his friends and family had observed changes in his behavior, and that he was emotionally numb or disconnected. These findings are consistent with this higher 50 percent rating for his PTSD, which contemplates reduced reliability and productivity and difficulty in establishing and maintaining effective relationships. Moreover, with the exception of his December 2008 VA examination, his GAF scores throughout the appeal period have not been greater than 55. At the very least, this suggest a moderate level of symptomatology, including symptoms such as a flattened affect and speech abnormalities, which are expressly contemplated by the schedular criteria for a 50 percent rating. An even higher 70 percent rating is not warranted, however. The Veteran's PTSD has not been characterized by many of the symptoms found in the criteria for this even greater rating, such as suicidal ideation, obsessional rituals that interfere with routine activities, illogical or irrelevant speech, a continuous panic or depression, spatial disorientation, or a neglect of hygiene. Notably, he did report being involved in several physical altercations, which reflects some impaired impulse control with periods of violence. He also reported occasional hallucinations during his VA examination. But, as discussed above, his remaining symptoms are all consistent with the 50 percent rating being awarded. The evidence does not show that impaired impulse control or occasional hallucinations result in the overall level of impairment that is contemplated by the 70 percent rating, including the inability to establish and maintain effective relationships. Similarly, while the evidence includes GAF scores of 35 to 45, none of his reported complaints and none of the symptoms documented by his treating clinicians are consistent with the higher 70 percent rating, as discussed above. In other words, while a GAF score of 45 is consistent with symptoms such as suicidal ideation or severe obsessional rituals, the evidence does not reflect any such findings. While a GAF score of 35 reflects impairment in reality testing, no such impairment was documented by the clinician who rendered that score. For these reasons, the 50 percent rating being awarded on appeal is the appropriate evaluation for the Veteran's PTSD. D. Extra-schedular Consideration In evaluating the Veteran's claim for a higher rating for this disability, the Board also has considered whether he is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors that would render its application impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected condition in considering whether he is entitled to an extra-schedular rating. According to the regulation, an extra-schedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extra-schedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the Rating Schedule for this disability shows the rating criteria reasonably describe his disability level and symptomatology. In other words, his symptoms, including his memory impairment, nightmares and sleep disturbances, and impaired impulse control, are all contemplated by the Rating Schedule. There is no indication his PTSD results in any symptoms that fall so far outside the Rating Schedule as to render it inadequate. ORDER A higher initial rating of 50 percent is granted for the PTSD, subject to the statutes and regulations governing the payment of VA compensation. REMAND As for the Veteran's remaining claim for service connection for residuals of a left eye injury, additional development is necessary. He contends that he sustained a left eye injury during his service. He had a VA examination in May 2008. He recounted that, in July or August 2004, he was too close to someone who fired their weapon during training. The resulting casings and links hit him in this eye. He immediately lost vision in this eye and later experienced blurriness and color-blindness. He was told he had "a permanent ripple and floaters" in his eye. He also complained of lost depth perception and other symptoms. The examiner diagnosed posterior vitreous detachment of the left eye, but did not offer any opinion as to the relationship, if any, between this condition and the Veteran's service - and, specifically, the alleged trauma. VA records from July 2008 show the Veteran underwent visual field testing. The evaluating physician opined that a conversion disorder was the cause of the Veteran's visual complaints. A VA opinion was obtained in January 2009. The examiner reviewed the claims file, including the prior VA examination and treatment records. He noted there were no records of an eye examination at the time of the injury in service. He also stated that the Veteran's May 2008 examination was essentially normal, without permanent injury to the eye, and that further testing in July 2008 had suggested a conversion disorder as a possible cause of his complaints. This examiner concluded there was no ocular injury or loss of vision evident on several eye examinations. Additional VA records dated in April 2009 noted complete left eye posterior vitreous detachment. When VA endeavors to provide a VA examination or obtain a VA opinion in response to a claim of entitlement to service connection, it must ensure the examination or opinion is adequate, else, notify the Veteran why one cannot or will not be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, while the Veteran has been diagnosed on more than one occasion with left eye posterior vitreous detachment, the record does not contain any medical nexus opinion specifically addressing whether this particular condition is related to his military service - and, specifically, the alleged trauma. Notably, the STRs do not contain any entries relating to the Veteran's reported injury in service. However, his Form DD Form 214 shows he was awarded the Combat Action Ribbon, which is prima facie indication he engaged in combat during his service. If, as here, a Veteran engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The U.S Court of Appeals for the Federal Circuit has held that, in the case of a combat Veteran, not only is the injury presumed, but so, too, is the disability due to the in-service injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). Therefore, this Veteran's statements of an in-service left eye injury are sufficient proof of said injury, as they are consistent with the circumstances, conditions and hardships of his service. To establish his entitlement to service connection, however, there still must be evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Therefore, this claim for a left eye condition must be remanded to obtain additional medical comment concerning whether the left eye posterior vitreous detachment in particular was incurred in service or is otherwise related or attributable to the Veteran's service, including the specifically alleged trauma. And as this claim is being remanded, the RO/AMC should also obtain all outstanding VA treatment records that may relate to this claimed condition. Accordingly, the claim is REMANDED for the following additional development and consideration: 1. Obtain the Veteran's VA treatment records since May 2010 - if relevant to this claim for a left eye condition said to be the result of trauma during his military service - and associate these additional records with his claims file for consideration. 2. Upon receipt of all additional records, forward the claims file to an appropriate VA compensation examiner. The examiner should review the Veteran's account of his left eye injury in service, as dictated in the May 2008 VA examination report, and must accept these statements as credible, irrespective of the lack of any documented eye injury in the STRs. The examiner must also review the findings in the July 2008 VA treatment records, January 2009 VA opinion, and April 2009 VA treatment records. The examiner must then provide medical comment regarding the likelihood (very likely, as likely as not, or unlikely) that the posterior vitreous detachment of the Veteran's left eye is the result of the left eye injury he presumably sustained during his military service. In formulating this opinion, the VA examiner should note that the term "as likely as not" means at least 50-percent probability. It does not, however, mean merely within the realm of medical possibility. Rather, it means that the weight of medical evidence both for and against a conclusion such as causation is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. It is essential the examiner discuss the underlying medical rationale of the opinion, whether favorable or unfavorable, and cite to specific evidence in the file supporting his conclusions if necessary. If the examiner determines the requested opinion cannot be provided without actually examining the Veteran, then schedule the Veteran for an appropriate VA examination. The Veteran has specifically requested that any appointments made for him be held at the Montrose or Castle Point VA medical facilities. The examiner conducting this examination must comply with the above instructions. 3. Then readjudicate this claim in light of this and all other additional evidence. If this claim continues to be denied, send the Veteran and his representative another supplemental statement of the case (SSOC) and give them time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. The Veteran has the right to submit additional evidence and argument concerning this claim the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs