Citation Nr: 1324082 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 12-20 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for a left eye disability, to include deterioration and loss of eye. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran had active service from October 1951 to November 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, which reopened the claim for service connection for a left eye disability and denied service connection on the merits. In an October 2012 decision, the Board reopened the claim for service connection for a left eye disability and remanded the claim for additional development. The case has now been returned to the Board for review. A video conference hearing was held in September 2012, with the Veteran sitting at the RO and the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of the hearing testimony is associated with the claims folder. The Veteran testified at a hearing before a Decision Review Officer (DRO) in April 2009. A transcript of the hearing testimony is associated with the claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's eyes were examined at entry into active service and were clinically found to be abnormal with visual acuity of 20/100 in the left eye, corrected to 20/40. 2. The most probative and competent evidence of record establishes that the pre-existing visual acuity disability of the left eye was not aggravated beyond its natural progression by active service. 3. Clear and unmistakable evidence establishes that traumatic cataract excision of the left eye to include residuals of persistent papillary membrane, left eye and strabismus, left eye, pre-existed active service. 4. Clear and unmistakable evidence of record establishes that the pre-existing disability was not aggravated by active military service. CONCLUSION OF LAW A left eye disability, to include loss of left eye and deterioration of vision, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to notify VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The October 2010 letter satisfied the duty to notify provisions, to include notifying the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Duty to assist With regard to the duty to assist, the claims file contains the service treatment records, private medical records, an October 2009 private medical opinion, and the statements and hearing testimony of the Veteran. The Board has carefully reviewed the statements and concludes that there has been no identification of further available evidence not already of record. The Board has perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a further duty to obtain. VA examinations were provided in July 2009 and January 2011 and a VA medical opinion was obtained in December 2012. When VA undertakes to provide a VA opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). First, the Board acknowledges that the July 2009 VA examiner only provided an opinion regarding direct causation and did not provide an opinion in terms of probability. However, the Board finds that the opinion is adequate as the examiner framed the opinion in unequivocal terms- opining that the Veteran's visual disability was not related to anything that happened while in the military and simply provides more support for the December 2012 VA examiner's opinion, which the Board has found to be the most probative and competent evidence of record. In the October 2012 remand, the Board found the January 2011 VA opinion to be inadequate as the examiner did not discuss the contention regarding the deterioration in the Veteran's visual acuity during active service or the October 2009 private medical opinion. The Board finds that the December 2012 VA medical opinion is adequate. The examiner reviewed the claims file, addressed the evidence of record, and provided a well reasoned rationale for the expressed opinion and specifically pointed to evidence in the service treatment records and post-service treatment records. Therefore, the Board finds the opinion is adequate and the October 2012 remand directives were substantially completed. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge (VLJ) and DRO who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the September 2012 Board hearing and April 2009 hearing before a DRO, the undersigned VLJ and DRO identified the issue on appeal. The undersigned VLJ and DRO also elicited testimony from the Veteran regarding her contentions, and the availability of any potentially significant outstanding evidence. The undersigned VLJ asked the Veteran regarding her in-service surgeries and whether she obtained an opinion from a physician to support her claim for service connection. See transcript, pgs. 3 - 6. The DRO also questioned the Veteran regarding her contentions related to active service and discussed the service treatment records. The Board finds that the undersigned VLJ and DRO fulfilled the duties under 38 C.F.R. § 3.103. To the extent that the duty to suggest the submission of evidence that may have been overlooked has not been sufficiently satisfied, the Board finds that any defect is not prejudicial to the Veteran. She was assisted at the Board hearing and the DRO hearing by her representative from AMVETS who also reiterated the evidence in the Veteran's case. The Veteran has demonstrated actual knowledge regarding the evidence necessary to substantiate the case by submitting relevant private medical records and a private medical opinion as to the issue of etiology in this case. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). In addition, neither the Veteran nor her representative has suggested any deficiency in the conduct of the hearings. Thus, the Board finds that any defect was not prejudicial to the Veteran and the Board may proceed with a decision. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to her claim. Legal criteria Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 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. See 38 C.F.R. § 3.303(d). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by a veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran avers that she lost her eye due to the development of glaucoma, which she relates to her in-service surgeries to the left eye. In a January 2009 statement, the Veteran explained that the surgery performed on her left eye while on active duty in 1955 contributed to the conditions which resulted in the development of glaucoma in her left eye, the inability to control the pressure in her left eye, and the eventual necessity of removal of her eye. During her April 2009 hearing before a DRO, conducted in connection with a prior appeal, the Veteran testified that she had sight until she developed glaucoma but as the pressure in her eye increased, her sight diminished. She stated that the process was very painful. She believed that it would not have developed if she hadn't had surgery on her eye in the first place. In another November 2011 statement, the Veteran explained that she was injured by a BB pellet hitting her left eye at age six. In October 1951, she was found to be qualified for enlistment in the United States Air Force with this pre-existing condition. She stated that the vision in her left eye was corrected to 20/40 as shown on the enlistment report of medical examination. She stated that she had two surgeries during active service- one in April 1955 and a second surgery in July 1955. When she was discharged, she pointed out that the vision in her left eye was 20/400 as noted on the separation report of medical examination. She stated that the vision in her left eye continued to be severely impaired following separation from service. She felt that the pre-existing condition could have been aggravated by the surgeries performed while she was in the military. The medical evidence, consisting of private treatment records dated from the 1980s to the 2000s, shows that the Veteran was diagnosed with glaucoma of the left eye and her left eye was removed in 2007, prior to her petition to reopen the claim of entitlement to service connection for loss of the left eye. The September 1951 enlistment report of medical examination shows that the Veteran's eyes - general (visual acuity and refraction under items 59, 60, and 61) were clinically evaluated as abnormal. The distant vision of the left eye was listed as 20/100 and corrected to 20/40. The distant vision of the right eye was 20/200 and corrected to 20/20. The pupils were clinically evaluated as normal. The Veteran was assigned an E-2 profile under the PULHES profile. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the "PULHES" profile reflects the overall physical and psychiatric condition of the veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service). The "PULHES" acronym designates "P" for physical capacity or stamina; "U" for upper extremities; "L" for lower extremities; "H" for hearing and ears; "E" for eyes; and "S" for psychiatric. She was found to be qualified for enlistment. A report of medical history completed for enlistment to active service shows that the Veteran checked yes as to experiencing eye trouble and indicated that she wore glasses. An April 1952 clinical record noted that the Veteran was struck in the left eye ("OS") twelve years ago at the age 6. On slit lamp examination, there was extrocapsular cataract extraction noted with respect to the left eye. There were some lens remnants in the left pupil. A March 1955 consultation sheet shows that the Veteran was interested in cosmetic correction of left, concomitant estropia of 10 to 12 degrees. A provisional diagnosis of left concomitant estropia was listed. It was noted that the estropia was secondary to surgical procedure dating back to age 6. An April 1955 clinical record reveals a diagnosis of persistent pupillary membrane, left eye, secondary to old dissection of traumatic cataract, due to an eye injury sustained when the Veteran was six years old. Details were not known. It existed prior to service (EPTS). The Veteran underwent an operation in April 1955 which involved a capsulotomy, lens, left. She was in the hospital for nine days. A July 1955 clinical record shows that the Veteran was diagnosed with strabismus, left eye, cause unknown. It was noted to have existed prior to service. The clinical record indicated that the Veteran was hospitalized for four days and underwent a recession of the eye muscle, left medial rectus. Another clinical record dated in July 1955 indicated that the Veteran had a traumatic dissection of cataract at age 6 and it was "ET" since that time. There were efforts made to straighten the eyes and fit them with contact lenses. The November 1955 separation report of medical examination shows that the Veteran's eyes were clinically evaluated as abnormal and the pupils were clinically evaluated as abnormal. With respect to the pupils, the examining physician indicated that there was irregularity of the left pupil. Under "Notes and Significant or Interval History," the physician indicated that the Veteran underwent excision of traumatic cataract in 1955 and correction of convergent strabismus. The examining physician noted that the traumatic cataract existed prior to service. The Veteran was provided a VA examination in July 2009. It was reported as medical history that, at age 6, she had a BB gun injury to her left eye. Subsequent to the injury to the left eye, the Veteran underwent cataract extraction for a traumatic cataract that developed from the injury. She said the next surgery she had was in 1955 while in the service and this was to straighten the left eye as well as an iridocapsulotomy of the left eye. Subsequent to these problems, she stated that she developed glaucoma in the left eye with multiple surgeries which eventually led to evisceration of the left eye in 2007. The examiner addressed pertinent evidence in the claims file and noted that the Veteran underwent a capsulotomy to the left eye in April 1955. The procedure was done because visual acuity in the left eye was poor after having a cataract extraction done in approximately 1940. In July 1955, the Veteran had recession of the left medial rectus muscle to improve and straighten the left eye. The private medical records noted that the Veteran reported to have developed symptoms of glaucoma in 1975-in the eye that suffered the trauma in 1940. The examiner noted that a March 1993 private treatment record indicated that the increased intraocular pressure was the result of traumatic cataract and angle-recession glaucoma. The March 1993 private treatment record stated that the only childhood disease was traumatic cataract and angle-recession glaucoma secondary to blunt trauma. The examiner opined that the problems with glaucoma in the left eye were not related to the capsuloctomy nor the medial rectus recession surgery done while in the service in 1955. The glaucoma was related to the blunt trauma that the Veteran suffered at age 6. She was well out of the service when in 1975, she developed glaucoma in the left eye. The examiner stated that blunt trauma can cause glaucoma in the affected eye 15 to 30 years later. The examiner indicated that the loss of the eye was related to the intractable glaucoma that she developed secondary to the trauma that she suffered at age 6 in 1940. The examiner acknowledged that the Veteran had a visual disability, but it was not related to anything that happened while in the military. In an October 2009 statement, the Veteran's private physician, Dr. K.Y., indicated that the Veteran had eye trauma at 6 years old in the left eye. Dr. K.Y. indicated that at the time of service and enlistment, her vision was 20/40 in the left eye. She underwent eye surgery in the military and ended up with 20/400 vision. He opined that the condition of the left eye may have been aggravated or acquired during surgery while in the military. Dr. K.Y. noted that the eye condition may have been related to medical service at the United States Air Force Hospital in 1955. VA obtained another medical opinion in December 2012. The examiner indicated review of the claims file. The examiner opined that the Veteran's active duty, including the left eye capsulotomy and correction of left eye strabismus, did not cause or aggravate a pre-existing left eye disability beyond its natural progression. Based on extensive review of ocular history found in the claims file, the examiner opined that the deterioration of visual acuity and post-service loss of the eye would most likely as not have occurred as previously stated during the January 2011 examination as well as the 2009 VA examination. The Veteran's extensive ocular course of the left eye was directly related to the injury sustained at 6 years old. The examiner also noted that there was no documentation that any in-service event caused the pre-existing condition to be aggravated beyond its normal progression. With respect to the left eye capsulotomy, the examiner stated that the surgery did not cause deterioration in vision. The examiner noted that the Veteran's documented visual acuity in the left eye on July 19, 1955 (prior to the strabismus surgery and after the capsulotomy) was not changed from her baseline best corrected vision of 20/40 in the left eye. The examiner also noted that the strabismus surgery was performed at the request of the Veteran for improved cosmetics and did not cause deterioration in vision of the left eye beyond its natural progression. The strabismus surgery would not cause the angle recession that led to the Veteran's intractable glaucoma. The examiner stated that there was not enough evidence to support a claim that the Veteran had deterioration in vision when comparing the enlistment and separation examinations as the documentation was incomplete and questionably inaccurate. It was not possible for the Veteran to have an uncorrected visual acuity better in the aphakic left eye compared to the normal right eye (Right: 20/200 versus left: 20/100). Also, the corrected vision was listed as 20/20 with respect to the right eye and 20/40 with respect to the left eye but did not state how the correction was obtained. The Veteran would not have been able to wear glasses (the weight of the lenses in the left eye versus the right eye would make it impossible for the Veteran to wear). The examiner noted that the separation report of medical examination showed that the distant vision was 20/400 for the left eye by glasses but not corrected. The examiner stated that this was further support for the opinion that this was not the best correctable vision possible for the Veteran's left eye. Finally, the examiner noted that the private physician's October 2009 opinion did not indicate an extensive review of all the medical evidence and was in contrast to all other eye care providers who either examined the Veteran or reviewed the claims file. At this examination, the Veteran had band keratopathy (likely limiting an examination/view of the angle structure and documentation of such was not provided) and was status post multiple glaucoma surgeries. Several other eye care providers indicated an examination of the angle structure noting extensive angle recession of the left eye secondary to trauma from a BB injury at six years old. Here, the Veteran has repeatedly contended that the development of glaucoma which led to the eventual removal of the left eye was caused or aggravated by her in-service left eye surgeries. The private treatment records beginning in the 1980s indicated that the Veteran developed glaucoma in the 1970s, many years after separation from active service. Indeed, in her own statement, the Veteran stated that her vision began to deteriorate when she was diagnosed with glaucoma. The private treatment records show that the Veteran underwent several surgeries with respect to the glaucoma. The Veteran's visual acuity was noted as 20/200 in January 1984. The records indicated that the Veteran underwent a trabeculectomy at age 43 and subsequently underwent several surgeries with respect to her glaucoma. Over time, the private treatment records reveal that the Veteran's visual acuity diminished and her left eye had no light perception (NLP) in the 1990s. The Veteran's left eye was removed in 2007 due to increased intraocular pressure and painful glaucoma. The private treatment records made no mention of the Veteran's period of active service or in-service surgeries, but have noted her traumatic injury at the age of 6. With respect to visual acuity or deteriorated vision, the enlistment report of medical examination shows that the Veteran's eyes - general (visual acuity and refraction under items 59, 60, and 61) were clinically evaluated as abnormal. The distant vision of the right eye was listed as 20/200 and corrected to 20/20 and the distant vision of the left eye was listed as 20/100 and corrected to 20/40. Again, the Veteran was assigned a physical profile of E-2. As such, there was no presumption of soundness as to the Veteran's left eye visual acuity on entrance to service. The question then becomes whether the pre-existing visual acuity disability of the left eye was aggravated by active service. The Board finds that the most probative and persuasive evidence is against service connection based on aggravation of a pre-existing disability. In this regard, the Board assigns the most probative weight to the opinion of the December 2012 VA examiner. The examiner reviewed the claims file, noted the service treatment records and post-service treatment records, and indicated that the Veteran's visual acuity of the left eye was not aggravated by active service. Specifically, the examiner stated: "In my professional opinion, the Veteran's active duty, including the left eye capuslotomy and correction or left eye strabismus, did not cause or aggravate a pre-existing left eye disability beyond its natural progression." The examiner stated that the course of the left eye was directly related to the injury sustained at six years old. The examiner went on to state that the left eye capsulotomy did not cause a deterioration in vision as the visual acuity in the left eye on July 19, 1955 (prior to the strabismus surgery) and after the capsulotomy was not changed from her baseline aphakic best correction vision of 20/40 in the left eye. With respect to the strabismus surgery, the examiner noted that it did not cause deterioration in vision of the left eye beyond its natural progression and that the surgery would not cause the angle recession that led to the Veteran's intractable glaucoma. The examiner noted that the separation examination report noted that the visual acuity of the left eye was 20/400. However, the examiner explained, by noting the findings in the service treatment records, that there was not enough evidence to support deterioration in vision as the documentation was incomplete and questionably inaccurate. The above-mentioned medical opinion is persuasive, as it is based on accurate facts, review of the claims file, and supported by a thorough explanation of the expressed opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight); also see Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based upon an inaccurate factual premise has no probative value). In contrast, as pointed out by the examiner who provided the December 2012 opinion, Dr. K.Y.'s opinion does not indicate whether the opinion was based on an extensive review of the claims file and was contrary to the other medical evidence of record which related the development of glaucoma and loss of the left eye to blunt trauma sustained when the Veteran was six years old-not the in-service surgeries. Further, the Board observes that Dr. K.Y. stated that the Veteran's eye condition may have been aggravated or acquired during surgery while in the military and that the Veteran's eye condition may have been related to medical service at the United States Air Force Hospital in 1955. The Board assigns little probative value to Dr. K.Y.'s opinion due to the use of speculative language. See Tirpak v. Derwinski, 2 Vet. app. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not exist" or "may or may not" be related, is too speculative to establish the presence of the claimed disorder or any such relationship). The probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. The Board finds that the most probative evidence does not support that the pre-existing visual acuity disability of the left eye was aggravated beyond its natural progression. Furthermore, the Board notes that the Veteran has repeatedly stated that she had a traumatic injury at the age of six years old and a traumatic cataract was excised at that time. With respect to the traumatic cataract and excision, the Board acknowledges that the enlistment report of medical examination only noted that the eyes - general (visual acuity, refractive error) were clinically evaluated as abnormal. The enlistment report of medical examination was absent for any mention or documentation of a prior traumatic cataract excision. The accompanying report of medical history was also absent for any mention of a traumatic cataract or excision of a cataract. Therefore, the Veteran is presumed sound. Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002); see also 38 C.F.R. § 3.304(b) (2012). The Board has carefully reviewed the evidence of record, taking into account the notations on enlistment, during, and subsequent to active service, and finds that there is clear and unmistakable evidence that the excision of a traumatic cataract and residuals thereof existed prior to service and clear and unmistakable evidence that the excision of a traumatic cataract and residuals were not aggravated by active service. An April 1952 clinical record, dated approximately six months after the Veteran entered active duty, notes that a slit lamp examination of the left eye revealed extrocapsular cataract extraction of the left eye and lens remnants in the left pupil. The Veteran was subsequently diagnosed with persistent pupillary membrane, left eye, secondary to old dissection of traumatic cataract, due to an eye injury sustained when the Veteran was six years old. The Veteran underwent an operation in April 1955 which involved a capsulotomy, lens, left. The Veteran also underwent an operation in July 1955 for cosmetic reasons to correct strabismus of the left eye. Indeed, the separation report of medical examination indicated correction of strabismus. VA regulations provide that there are medical principles so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of disability prior to service is established, no additional or confirmatory evidence is necessary. Consequently, with notation or discovery during service of such residual conditions, including congenital malformations, with no evidence of the pertinent antecedent active disease or injury during service the conclusion must be that they pre-existed service. 38 C.F.R. § 3.303(c). Here, the most competent and probative clinical evidence shows that the Veteran's traumatic cataract excision occurred prior to active service. Again, the April 1952 clinical record noted that the cataract was removed and there were lens remnants secondary to such a removal. Further, the subsequent clinical records noted diagnoses of persistent pupillary membrane, left eye, and strabismus of the left eye secondary to the traumatic cataract dissection when the Veteran was six years old. Thus, the Board finds that the probative and competent clinical records constitutes clear and unmistakable evidence that the traumatic cataract dissection and residuals consisting of persistent pupillary membrane, left eye, and strabismus of the left eye existed prior to the Veteran's period of active service. Additionally, the most persuasive, probative, and competent evidence demonstrates that it is clear and unmistakable that the pre-existing left eye disability was not caused or aggravated by active service. The Board assigns significant probative value to the December 2012 VA examiner's opinion. Again, the examiner opined: "In my professional opinion, the Veteran's active duty, including the left eye capsulotomy and correction or left eye strabismus, did not cause or aggravate a pre-existing left eye disability beyond its natural progression." The examiner stated that the course of the left eye was directly related to the injury sustained at six years old. The December 2012 VA examiner's opinion is also supported by the opinion of the July 2009 VA examiner. In this regard, the Board recognizes that the July 2009 VA examiner did not express an opinion as to whether a pre-existing disability was aggravated by active service. However, the examiner stated that the loss of the eye was not caused by or the result of the surgeries the Veteran had during service in April 1955 and July 1955. The examiner stated: "The loss of the eye is related to the intractable glaucoma that she developed secondary to the trauma that she suffered at age 6 in 1940. The Veteran obviously does have visual disability at this point due to the loss of eye, but this is not related to anything that happened while in the military." The examiner also noted that the first surgery was done secondary to the traumatic cataract suffered in 1940 and that the second operation was also done secondary to the trauma she suffered at age 6 and that the Veteran developed glaucoma in the left eye that is the eye that had trauma. The unequivocal language used by the April 2009 VA examiner supports the December 2012 VA examiner's opinion that any pre-existing disability was not caused or aggravated by active service. In addition, a private medical record dated in March 1993 also provides support for the opinion as it was noted that the Veteran's only childhood disease was traumatic cataract and she had angle-recession glaucoma secondary to blunt trauma. The Board finds that the most persuasive and competent evidence reflects that it is clear and unmistakable that the Veteran's pre-existing disability existed prior to service and it is clear and unmistakable that the disability was not aggravated by active service. Additionally, the most probative evidence does not relate the Veteran's left eye disability to any in-service disease, event, or injury, but relates her disability to trauma incurred when she was six years old. The Board acknowledges Dr. K.Y.'s medical opinion. However, as noted above, the Board affords the October 2009 medical opinion very little probative value. Dr. K.Y. opined that the pre-existing condition may have been aggravated or caused by service. The Board assigns little probative value to Dr. K.Y.'s opinion due to the use of speculative language. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In addition, Dr. K.Y. did not note whether he reviewed all of the service treatment records or private treatment records, which are pertinent in providing an opinion as to whether a pre-existing disability was aggravated by active service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the only evidence relating the Veteran's glaucoma and loss of left eye to her in-service surgeries are her own statements. Again, the most probative and competent medical evidence has related the Veteran's ocular problems to the traumatic cataract and blunt trauma incurred when she was six years old- not to her period of active service. Although the Veteran is competent to provide statements regarding lay-observable symptoms, she is not competent to provide an opinion as to the etiology of her glaucoma and loss of her left eye. The Board is mindful that competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); see also Barr v. Nicholson, 21 Vet App 303 (2007). However, the Board finds that the Veteran's statements regarding etiology are not competent. The issue of etiology of an eye disability is a complex medical question, which the Veteran is not competent to address as she has not been shown to have had any medical training or medical expertise. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a left eye disability, to include deterioration and loss of eye, is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs