Citation Nr: 1340549 Decision Date: 12/09/13 Archive Date: 12/20/13 DOCKET NO. 11-05 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for cataracts, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for atrial fibrillation, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL Appellant and Appellant's wife ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from October 1967 to July 1969. This appeal comes to the Board of Veterans' Appeals (Board) from a September 2009 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran provided sworn testimony in support of his appeal during a hearing before the undersigned Veterans Law Judge in September 2013; the hearing transcript has been associated with the file and has been reviewed. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Cataracts are caused by service-connected diabetes mellitus. 2. The preponderance of the competent evidence of record is against finding that the Veteran's currently diagnosed atrial fibrillation was incurred in or aggravated by active service or is due to or aggravated by a service-connected disability, to include diabetes. CONCLUSIONS OF LAW 1. The criteria for service connection for cataracts have been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 2. The criteria for service connection for atrial fibrillation have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2013). Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease, will be service-connected. Id.; Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran is service-connected for diabetes mellitus and contends both his cataracts and atrial fibrillation are secondary to his diabetes. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Cataracts Private treatment records reflect that the Veteran had an extracapsular cataract extraction in his right eye in March 2007 and in his left eye in September 2007. In September 2008 the Veteran's treating physician authored a letter in which he stated that the Veteran was diagnosed with cataracts in 2003 and the type of cataracts he had "are often caused by diabetes." The Veteran was afforded a VA examination in February 2009. The examiner stated that without having seen the cataracts prior to their removal in 2007, he could not opine as to whether the Veteran's cataracts were secondary to or aggravated by his diabetes. The Veteran submitted a number of internet print outs, including a Journal of Ophthalmology article stating that several clinical studies have shown cataract development occurs more frequently and at an earlier age in those with diabetes and information from the American Diabetes Association stating that people with diabetes are 60 percent more likely to develop cataracts. The Board finds that, after affording the Veteran the benefit of the doubt, he is entitled to service connection for his cataracts as secondary to his service-connected diabetes. Although the Veteran's treating physician did not offer an opinion specifically stating that the Veteran's cataracts were caused by his diabetes, he did state that the type of cataracts the Veteran had are often caused by diabetes. The doctor's statement was not refuted by the VA examiner, who stated that he could not offer an opinion without having seen the cataracts prior to their removal. As the Veteran's treating physician did see the cataracts prior to their removal, the Board affords his opinion significant weight. In addition, the medical literature submitted by the Veteran supports that the claim that diabetics are more likely to develop cataracts and that they often develop a certain type. Therefore, service connection for cataracts as secondary to service-connected diabetes mellitus is granted. Atrial Fibrillation In July 2008 the Veteran's primary care physician authored a letter stating that the Veteran has had hypertension for close to ten years and adult onset diabetes for six years. He noted the Veteran is on medication including Lopressor and lisinopril. In September 2008 the physician who treated the Veteran for his atrial fibrillation authored a letter in which he stated that the Veteran has a history of atrial fibrillation, diabetes mellitus, and hypertension and that "both the diabetes and hypertension are considered risk factors for the development of atrial fibrillation." The Veteran was afforded a VA examination in February 2009. The examiner stated that the Veteran had an approximately 10-year history of hypertension documented by his family care physician and was first diagnosed with atrial fibrillation in 2007. The examiner diagnosed the Veteran with hypertension well-controlled with antihypertensive therapy. He opined that the Veteran's hypertension was not caused or aggravated by his diabetes. He also diagnosed the Veteran with chronic and intermittently recurring atrial fibrillation. He opined that it is as likely as not related to the Veteran's hypertension and not caused or aggravated by his diabetes. The Veteran also submitted internet print outs regarding a relationship between atrial fibrillation and diabetes mellitus, including a Journal of Cardiovascular Disease research article concluding that there is an association between atrial fibrillation and diabetes mellitus but that causal links would need to be verified in a large cohort study and an International Journal of Cardiology article discussing a study that found that diabetes mellitus is a strong, independent risk for the occurrence of atrial fibrillation and flutter and other cardiovascular disease. Also included were summaries of a Journal of General Internal medicine article describing a study in which patients with diabetes were 40 percent more likely to be diagnosed with atrial fibrillation than those without diabetes. 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). The two competent medical opinions in this case come from the Veteran's private doctor and the VA examiner. The Veteran's private doctor noted only generally that hypertension and diabetes are risk factors for atrial fibrillation, without opining specifically as to whether either or both caused or aggravated the Veteran's atrial fibrillation. However, the VA examiner opined that the Veteran's atrial fibrillation was related to his hypertension and was not caused or aggravated by his diabetes. Thus, the available medical opinion evidence addressing specifically the facts of the Veteran's individual case does not support secondary service connection for the Veteran's atrial fibrillation. While the Board has considered all of the articles submitted by the Veteran, the Board finds they are of limited probative value as the articles do not apply medical principles regarding causation or etiology to the facts of the Veteran's individual case nor is there a medical opinion of record discussing the articles in the context of the Veteran's individual situation. See Sacks v. West, 11 Vet. App. 314 (1998); Libertine v. Brown, 9 Vet. App. 521 (1996). The Board further finds that the Veteran's own opinion that his diabetes is the cause of his atrial fibrillation is not competent or probative evidence in support of his claim. Competent lay evidence is 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). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). While the Veteran is competent to state what symptoms he feels, such as his heart racing, the etiology of atrial fibrillation is a complex medical question not capable of lay observation and not the type of medical issue for which a lay opinion may be accepted as competent evidence. Thus, the Board finds that the evidence does not support that the Veteran's atrial fibrillation is caused or aggravated by his service-connected diabetes mellitus. The Board further finds that the evidence does not support service connection for atrial fibrillation on a direct basis. The Veteran has not contended and the evidence does not show that he had atrial fibrillation in service or that it was caused by any injury or event in service. At his Board hearing, the Veteran, who was 24 when he left service, testified he first felt his heart race in his late twenties after exercising but that it always returned to normal after he sat down and relaxed. The Veteran first sought treatment for atrial fibrillation, leading to his diagnosis, in 2007, nearly 40 years after service. The Board also notes that while it has been conceded that the Veteran was exposed to herbicide in service, atrial fibrillation is not among the diseases that is presumptively associated with herbicide exposure. 38 C.F.R. § 3.309(e). As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply, and the claim for a service connection for atrial fibrillation must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Duties 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 and 3.326(a). As the Board has granted service connection for cataracts any error committed with respect to that claim was harmless and will not be discussed. However, the Board has considered the duties with respect to the Veteran's claim for service connection for atrial fibrillation and finds that the duties were met. A notice letter was sent to the Veteran in October 2008, prior to the initial adjudication of the increased rating claim on appeal. The letter informed the Veteran of what information and evidence must be submitted to substantiate the claim, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. He was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claim to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The undersigned VLJ who conducted the September 2013 hearing also complied with the duties to fully explain the issues on appeal and suggest the submission of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran was assisted at the hearing by an accredited representative from the Vietnam Veterans of America, and the VLJ and the representative asked questions regarding the nature and etiology of the Veteran's atrial fibrillation. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records and private treatment records identified by the Veteran. The Veteran also submitted lay statements. 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 Veteran was afforded a VA medical examination in February 2009. The examiner, a medical professional, obtained an accurate history, including with respect to the Veteran's history of hypertension; listened to the Veteran's assertions; performed the necessary tests; and provided an opinion as to etiology. Therefore, the Board finds that the examination is adequate and contains sufficient information to decide the issue on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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); see also Quartuccio, 16 Vet. App. 183. ORDER Service connection for cataracts is granted. Service connection for atrial fibrillation is denied. ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs