Citation Nr: 1410113 Decision Date: 03/12/14 Archive Date: 03/20/14 DOCKET NO. 10-12 437 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for macular degeneration. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jennifer R. White, Counsel INTRODUCTION The Veteran served on active duty from August 1964 to July 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In June 2010, the Veteran testified before RO personnel concerning the issue of entitlement to service connection for hypertension. A transcript of that hearing is of record. In December 2013, the Veteran testified at a Board hearing by way of videoconference technology before the undersigned Veterans Law Judge. A transcript of that hearing is of record. REMAND Service connection may be established on a secondary basis for a disability that is caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310 (b), added effective October 10, 2006, 71 Fed. Reg. 52744-52747 (Sept. 7, 2006). The Veteran contends that he has hypertension that is related to in-service exposure to Agent Orange. The Board notes that exposure to Agent Orange was conceded by the RO in a March 2011 rating decision, noting that records from official sources indicated service in the inland waterways of Vietnam. Concerning the Veteran's hypertension, a March 2011 VA examination indicated that this disability was not caused or aggravated by his service-connected diabetes mellitus. However, this is no explanation for such a conclusion. Additionally, there was no consideration of the Veteran's allegation concerning a direct link between his hypertension and an in-service event, specifically Agent Orange exposure. Thus, as the Veteran has indicated a confirmed event in service (herbicide exposure) and has a diagnosis within the relevant period for his claimed disability, the Board must remand the claim for a medical opinion concerning any nexus that may exist. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the Veteran's claim for service connection on the basis of aggravation of macular degeneration, the Veteran claims that he has worsened macular degeneration due to the administration of Plavix to treat his service-connected ischemic heart disease. The Board notes that macular degeneration in both eyes was noted in a January 2006 private treatment note. The Veteran was treated at a private hospital in August 2007 with clopidogrel (Plavix) for a heart attack. A letter dated in July 2008 from the Veteran's physician indicates that the Veteran ". . . apparently had a retinal hemorrhage secondary to Plavix that resolved[,] but he still remains on Plavix." The physician noted that he had no records of the eye impairment. An August 2008 treatment note from Dr. M indicates "macular degeneration OU and traumatic retinopathy????" A letter from Dr. M dated the same month indicates that, "In the left eye, the macular degeneration is wet with bleeding aggravated by Plavix he took for a heart condition." A VA examination report dated in May 2013 indicates that the medical literature suggests a retrospective relationship between anti-coagulate therapy and the development of subretinal hemorrhages, but it was also noted that an association has not been prospectively studied for confirmation of such preliminary findings. Because the Veteran's treatment history was not unique it was felt that it was clinically impossible to positively state that the Plavix exacerbated his macular degeneration. The Veteran has also submitted medical literature indicating that retinal hemorrhage is a rare side effect of use of Plavix. Thus, the record appears somewhat equivocal on the question of whether there was aggravation beyond the normal progression of the Veteran's macular degeneration because of the use of Plavix. Moreover, none of the positive opinions indicate a baseline of the disability prior to any aggravation. Thus, the Board finds that an additional opinion is necessary. Additionally, the Board notes that additional VA treatment records have been added to the electronic file since certification to the Board. Thus, such records must be considered on readjudication. Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA treatment records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, this case is REMANDED to the agency of original jurisdiction (AOJ) for the following actions: 1. Obtain and associate with the claims files any pertinent records adequately identified by the Veteran, including any ongoing medical records from the St. Louis VA Healthcare System. 2. Thereafter, the Veteran should be afforded a VA examination relative to his hypertension claim. The claims folders must be made available to and reviewed by the examiner. Based upon the examination results and the review of the claims folders, the examiner should state the medical probabilities that hypertension is traceable to the Veteran's period of active military service, or events coincident therewith, such as exposure to herbicides. The examiner must also comment as to whether the Veteran's hypertension has been caused or made worse by any service-connected disability. The rationale for all opinions expressed must be provided. 3. The Veteran should be afforded a VA examination by an ophthalmologist. The claims folders must be made available to and reviewed by the examiner. The examiner should state the medical probabilities that macular degeneration was caused by or made chronically worse by any service-connected disability or treatment therefor, to include Plavix treatment. (If aggravation is found, to the extent that it is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the macular degeneration before the onset of aggravation.) A rationale is necessary for all opinions expressed. 4. Thereafter, the AOJ should readjudicate the claims on appeal. If a benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and provided an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).