Citation Nr: 1335125 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-12 660 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for glaucoma of the left eye (claimed as a left eye injury). REPRESENTATION Appellant represented by: Mr. Earl A. Koontz, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1980 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 RO decision, which denied a claim for service connection for glaucoma. In August 2010, a Travel Board hearing was held before the undersigned Veterans Law Judge at the Winston-Salem, North Carolina RO. A transcript of that proceeding has been associated with the claims folder. In November 2010, the Board remanded the matter on appeal to the RO (via the Appeals Management Center (AMC)) for additional development. The Board instructed that the RO attempt to obtain outstanding records of VA treatment identified by the Veteran and to provide the Veteran with a VA eye examination. The record reflects that unsuccessful attempts were made to obtain records from VA medical facilities in Salisbury, North Carolina and in Mountain Home, Tennessee. The Veteran was afforded a VA eye examination in December 2010. The Board finds substantial compliance with the requirements articulated in the Board's 2010 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board notes that additional VA treatment records have been received after the most recent supplemental statement of the case (SSOC) was issued in June 2012 with respect to this claim. However, given the favorable decision below, the Board finds no prejudice to the Veteran. FINDING OF FACT There is at least an approximate balance of positive and negative evidence as to whether the Veteran's glaucoma of the left eye is causally related to his period of service. CONCLUSION OF LAW Resolving doubt in favor of the Veteran, the criteria for establishing service connection for glaucoma of the left eye have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION 1. VA's Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Here, in view of the Board's favorable decisions to grant service connection for glaucoma of the left eye, any further discussion as to any shortcomings in duties to assist and notify, or regarding whether the Veteran was prejudiced by any such lapses, would serve no useful purpose. 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. The Veteran seeks entitlement to service connection for glaucoma of the left eye. The Veteran asserts that he injured his left eye while in training in the service. Specifically, the Veteran asserts that, while he was in training in approximately March or April of 1981, he was hit with a weapon butt in the eye. He claims he was treated for this injury in service, and he has continuously sought treatment over the years for this injury. See the August 2010 Board hearing transcript. A review of the Veteran's service treatment records reveals no documentation of an injury of any kind to the left eye. On his January 1980 enlistment Report of Medical Examination, the Veteran's distant vision was recorded as a 20/30 bilaterally. His near vision was recorded as a J-2 for the right eye and J-4 for the left eye. In a February 28, 1980, service treatment record, 2 days after his enlistment into active duty, the Veteran's visual acuity was recorded as 20/20 for the right eye and 20/60 for the left eye. In a September 1980 service treatment record, the Veteran reported blurred vision. However, this was associated with a mild headache and dizziness and the Veteran as diagnosed with nasal congestion. On the Veteran's July 1982 separation Report of Medical Examination, the Veteran's distant vision was recorded as a 20/20 for the right eye and a 20/35 for the left eye. His near vision was recorded as a J-1 for the right eye and J-3 for the left eye. The available VA treatment records show that the Veteran has been diagnosed with primary open angle glaucoma bilaterally. These records also note that him as being status post trauma of the left eye and having traumatic glaucoma of the left eye. In September and October 2005 VA treatment records, the Veteran reported that he thought his trauma to the left eye was related to his job and insulation getting in his eyes. In a separate September 2005 VA treatment record, the Veteran was noted as having left eye reduced acuity due to glaucomatous cupping secondary to trauma in 1981 and also suspected refractive amblyopia component. In a May 2009 VA treatment record, the Veteran was noted as having trauma in 1981 to the left eye during military training. In a July 2009 VA eye surgery consultation record, the Veteran was noted as having traumatic glaucoma of the left eye and ocular hypertension of the right eye. At this consultation, the Veteran reported that, in 1981, he had a kick back from a weapon in his foxhole and suffered ocular trauma. He stated that he was not started on any eye medications until years later. Pursuant to the Board's November 2010 remand directives, the Veteran was afforded a VA eye examination in December 2010. That examination report shows a diagnosis of severe left eye glaucomatous optic atrophy with loss of visual acuity and loss of visual field. Based on a review of the Veteran's service treatment records, the Veteran's reported history of in-service trauma to the left with the butt of a rifle and treatment with a eye patch, as well as the findings of asymmetrical advanced glaucoma in the left eye oppose to the right, the VA examiner opined that it was most likely that the Veteran's current advanced glaucoma in the left eye is related to his period of service. The examiner noted that although there was no documentation of in-service left eye trauma, the Veteran's description of the event and the manner in which it was handled in the field was consistent with treatment to blunt trauma to the eye. The examiner also noted that the findings of severe advanced glaucoma in only the left eye was very consistent with a past event of blunt trauma injury to the eye. The examiner further commented that the findings of decreased visual acuity in the Veteran's left eye at separation also suggested that the Veteran suffered an injury to his left eye during his period of service. Based on a review of the evidence of record, the Board finds that when viewed in the light most favorable to the Veteran, the record established that his current advanced glaucoma of the left eye is related to his period of service. The medical records establish that the Veteran has a current diagnosis of glaucoma in the left eye. See the report of a December 2010 VA examination as well as VA treatment records. There is also evidence suggesting in-service incurrence of a left eye injury. The Veteran has provided competent and credible lay evidence that he sustained an in-service left eye trauma when he was struck in the left eye with the butt of a rifle. He has also provided competent and credible lay evidence regarding the treatment with an eye patch following the left eye trauma. See Layno v. Brown, 6 Vet. App. 465 (1994). While the Veteran's service treatment records do not corroborate his reports of an in-service left eye trauma, his July 1982 separation examination does show the findings of decreased visual acuity in the left eye at separation, which the December 2010 VA examiner opined were consistent with an injury to the left eye. However, none of the subsequent service and post-service treatment records shows glaucoma or any other chronic eye disorder was diagnosed in service or within the first year thereafter. Despite the Veteran's reports that he has experienced left eye problems during his period of service as well as in the years following thereafter, the record does not show findings of chronic left eye disorder, glaucoma, until 2005. The 2005 VA treatment record also note the Veteran's reported history of an intervening left eye trauma after getting insulation in his eye at work. Nevertheless, there is a persuasive medical opinion that links the Veteran's current glaucoma in his left eye to his reported in-service injury and subsequent treatment described above. The December 2010 VA examiner's opinion is afforded high probative value, as it was made after a review of the relevant evidence, including the service treatment records and the Veteran's reported history, and contains a rationale for the conclusion reached. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3. Consequently, resolving any doubt in the Veteran's favor, the Board finds that the Veteran's glaucoma in the left eye is likely related to service. Hence, service connection for glaucoma of the left eye is warranted, and the claim is granted in full. See 38 C.F.R. § 3.303 ORDER Entitlement to service connection for glaucoma in the left eye is granted. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs