Citation Nr: 1536574 Decision Date: 08/26/15 Archive Date: 09/04/15 DOCKET NO. 13-17 808 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for photophobia. REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION This appeal was processed using the Veteran's Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In addition to the VBMS file, there is a Virtual VA paperless claims file associated with the claim. The Veteran had active service from June 1979 to June 1982 with subsequent service in the Army National Guard of Pennsylvania. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran filed a notice of disagreement in July 2012 and was provided with a Statement of the Case in April 2013. The Veteran perfected his appeal with a June 2013 VA Form 9. In the May 2015 decision, the Board denied the Veteran's claim for service connection for residuals of a traumatic brain injury (TBI), and remanded the current issues on appeal for additional development. As will be discussed further herein, as to the issue being decided herein, the Board finds that the agency of original jurisdiction substantially complied with the remand orders, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to service connection for headaches is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT The Veteran's photophobia did not manifest in service, and is not the result of any injury or disease incurred or aggravated in line of duty during ACDUTRA or from any injury incurred or aggravated during INACDUTRA, or otherwise related to any injury or disease from active duty. CONCLUSION OF LAW The Veteran's photophobia was not incurred in active service, nor was it incurred or aggravated during any period of ACDUTRA or INACDUTRA. 38 U.S.C.A. §§ 101, 106, 1101, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.1 , 3.6, 3.102, 3.159, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board will address the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2014). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)(2014). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. In this respect, through an October 2011 notice letter, the Veteran received notice of the information and evidence needed to substantiate his claim. Thereafter, he was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board finds that the October 2011 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In the letter, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned October 2011 letter. In addition, this letter provided the Veteran with information regarding the type of evidence necessary to establish a disability rating and an award of an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 472 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board finds that the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the notice requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim on appeal. The Veteran's service treatment records as well as all identified and available VA and private treatment records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the service connection claim adjudicated herein. The Board notes that the RO made several attempts to obtain treatment records issued at the Lebanon VA Medical Center (VAMC) dated from January 1995 to June 2007. Unfortunately, the RO was unable to retrieve these records, and in January 2012, the RO issued a Formal Finding on the Unavailability of Outpatient Treatment Records for this period, listing the various attempts made to locate the Veteran's records. According to the memorandum, all procedures to obtain records pertaining to the Veteran had been correctly followed, all efforts to obtain the needed information had been exhausted, and any further attempts were futile. Significantly, neither the Veteran, nor his representative, has otherwise alleged that there are any outstanding medical records probative of his claims on appeal that need to be obtained. In addition, the Veteran was afforded a VA medical examination for his claimed photophobia in March 2012. Pursuant to the May 2015 remand, the Veteran's claim was referred to a VA optometrist for an additional medical opinion addressing the etiological origin of the photophobia, and specifically whether the claimed photophobia was related to his military service, to include his period of service in the Army National Guard. The medical opinion was issued in June 2015 and has since been associated with the VBMS file. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Board finds that the VA examination was predicated on a physical examination of the Veteran's eyes as well as consideration of the medical records in the Veteran's claims file and the Veteran's reported history. Additionally, the June 2015 medical opinion was predicated on a complete review of the claims file, considered all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examination, and provided a complete rationale for the opinions stated. The Board finds that examination report in conjunction with the medical opinion provided contains sufficient evidence by which to decide the claim, particularly regarding whether the claimed disability can be attributed to any period of ACDUTRA or INACDUTRA. The Board finds that collectively, the examination report and opinion are adequate for purposes of rendering a decision in the instant appeal. 38 C.F.R. §4.2 (2014); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the requirements of the remand were ultimately accomplished and the prior remand instructions pertaining to the issue of service connection for photophobia were substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board observes that, with respect to the Veteran's National Guard service, the applicable laws and regulations permit service connection only for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or injury incurred or aggravated while performing inactive duty for training (INACDUTRA). See 38 U.S.C.A. § 101(22), (24); 38 C.F.R. § 3.6. In his September 2011 application, the Veteran asserted that his photophobia was incurred during his military service, and specifically during his period of service in the Army National Guard. Specifically, the Veteran contends that he was injured during his second tour in the National Guard when an immersion heater exploded and threw him fifteen feet into the air, and as a result he fell against a tree and was rendered unconscious for several minutes. According to the Veteran, he was blind for a period of time after he recovered. The Veteran claims to experience vision issues as a result of this in-service injury. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for his photophobia. Turning to the service treatment records, the Board notes that at the May 1979 enlistment examination, the clinical evaluation of ophthalmoscopic system was absent any abnormalities, and the Veteran denied a history of eye trouble in the medical history report. In March 1980, the Veteran presented at the military clinic with complaints of a swollen eye of one day duration. He was assessed with having acute sinusitis. In the September 1984 consultation report, the physician noted that the Veteran experienced a seizure the previous March while serving in the National Guard. During the evaluation, the Veteran denied experiencing any headaches, double vision, loss of vision, weakness, numbness or tingling. On examination, his pupils were described as equal, round and reacting well to light and accommodation. Results of the fundus exam revealed sharp discs, and the visual fields were full to confrontation. In addition, the Veteran's extraocular movements were shown to be full. At the July 1988 enlistment examination into the National Guard, the clinical evaluation of the eyes and ophthalmoscopic system was shown to be normal. Indeed, the Veteran's visual acuity for distant objects without correction was 20/20 in the right eye and 20/25 in the left eye. In addition, the Veteran denied a history of eye trouble in the medical history report. An Individual Sick Slip report dated in June 1990 reflects that the Veteran was seen at sick bay after an immersion burner exploded on his face and removed his hair from the eyes up to the forehead. The progress notes reflect that the Veteran's face was burning and his eyes were red. The notes further reflect that his eyes were treated with Alcaine and another ophthalmic solution. Upon physical examination of the eyes, the treatment provider observed no evidence of a corneal abrasion. It was noted that "[t]wo Ben 25 mg was given to PT" and patches were placed on his eyes for four hours. A follow-up treatment report dated the same day reflects that the Veteran was seen at the clinic once again, at which time his patches were removed, and minimal signs of swelling were evident in the eyes. Upon replacing the patches, the Veteran reported to have pain, and he was given 650 mg of Tylenol to treat his symptoms. The Veteran's eyes were monitored for the next 24 hours, during which time the swelling, pain, discomfort and redness in his eyes appeared to diminish and subside. He was deemed fit for duty the following day. At the June 1992 medical examination pursuant to the Veteran's enlistment into the Army National Guard, clinical evaluation of the eyes, pupils, and ophthalmoscopic system was shown to be normal. The Veteran's visual acuity for distant and near objects without correction was 20/20 in both eyes, and the Physical Profile report reflects that he had a physical profile of 'E1' at the time of this examination. 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)). In addition he denied a history of eye problems or loss of vision in either eye in his medical history report. He was deemed qualified for service in the Army National Guard. At the February 2002 physical examination, clinical evaluation of the ophthalmoscopic system was negative for any abnormalities. The Veteran's visual acuity for distant objects without correction was 20/20 in both eyes, and his visual acuity for near objects without correction was 20/25 in both eyes, with corrected visual acuity of 20/20. The Physical Profile report reflected a visual profile of 'E1' at the time of this examination. As such, the records from the Veteran's periods of active service, as well as his periods of service in the Army National Guard do not reflect any complaints of, or treatment for problems or issues concerning his eyes, and the evidence does not indicate that the Veteran was disabled from a disease or injury incurred or aggravated in line of duty during a verified period of ACDUTRA, or that he was disabled from an injury incurred or aggravated in line of duty during a verified period of INACDUTRA. Although the immersion heater explosion did temporarily injure the Veteran's eyes, there were no signs of a permanent injury as a result of this explosion given that physical examination of the eyes was absent any indication of a corneal abrasion, and the clinical records and progress notes reflect that he was deemed fit for duty the following day. Moreover, the subsequent examination reports and treatment records are absent any complaints of, or treatment for eye problems following the June 1990 injury. The post-service treatment records pertaining to the Veteran's claimed photophobia include the January 2011 Emergency Department Nursing Discharge report which indicates that the Veteran was admitted to this facility after blacking out the day before. The narrative summary listed some of the Veteran's symptoms, and reflected signs of slight photophobia. Report of the July 2011 optometry visit includes the Veteran's self-reported medical history, and specifically his recollection that after losing his vision for a five-to-ten minute duration following the in-service explosion, he had not experienced any problems since. During the visit, the Veteran stated that he lost his glasses and wished to obtain a new pair with preferably tinted/transition lenses given that he was very photophobic. On examination, his visual acuity without correction was 20/30 in the right eye and 20/50 in the left eye. Based on her evaluation of the Veteran, the treatment provider assessed the Veteran with having refractive error, and specifically hyperopia and presbyopia in the eyes. The treatment provider noted that new bifocals were being ordered with transition lenses for the Veteran's photophobia that was "induced by medications." Report of the February 2012 optometry note reflects the treatment provider's notation that the Veteran uses transition lenses and lined bifocals, is extremely sensitive to light and is currently taking anti-psychotic medication for treatment of his depression. The Veteran was afforded a VA examination in connection to his eye disability in March 2012, at which time the examiner evaluated the Veteran's eyes and noted that his visual acuity for distant objects without correction was 20/50 in the right eye, and 20/70 in the left eye. In addition, the Veteran's visual acuity for objects that were closer in proximity without correction was 20/100 in both eyes, and his visual acuity for distant and near objects with correction was 20/40 in both eyes. Slit eye lamp findings were normal and tonometry examination results revealed the eye pressure to be 13 bilaterally. There was no diplopia present and funduscopic examination was absent any abnormalities. The examiner noted that the Veteran had a visual field defect and visual field testing revealed "30-5 fdt screening." It was further noted that results of this testing were questionable. The remainder of the examination was clear for any other abnormalities. Based on the VA examiner's discussion with, and evaluation of the Veteran, the examiner determined that the Veteran's photophobia was a subjective complaint and there was no evidence of ocular injury or disease on examination. Subsequent VA treatment records include a number of optometry treatment notes and eye examination reports reflecting the Veteran's request for tinted glasses. In the April 2014 optometry report, the VA optometrist noted that the Veteran had been allowed transitions in the past due to anti-psychotic medicine use. In the May 2015 remand, the Board acknowledged the March 2012 VA examiner's conclusion but noted that the Veteran's photophobia was subjective and a manifestation that is capable of lay observation by the person experiencing it. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). As such, the claim was remanded and the Veteran's claims file was referred to another VA physician for a medical nexus opinion addressing whether the photophobia was incurred in service. Based on his review of the records, the VA optometrist determined that the Veteran's photophobia was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In reaching this opinion, the VA optometrist noted there to be no evidence the Veteran's in-service injury caused anything that would result in chronic photophobia. According to the examiner, the in-service documentation reflects that physical examination of the eye was absent any evidence of scarring in the corneal, iris or retinal area - something that would be expected to be present if such an injury occurred that would yield lasting symptoms. The VA optometrist also took note of the July 2011, February 2012, April 2013, August 2013, and April 2014 medical reports which showed tinted glasses (transitions) ordered at each visit for photophobia deemed secondary to medications. According to the examiner photophobia is a known side effect of many anti-psychotic and anti-depressive medications that have been used by the Veteran. In considering all the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for his photophobia. In this regard, the Board acknowledges that the objective medical findings reflect that the Veteran has been diagnosed with having photophobia. As previously discussed above, there is a lack of evidence reflecting any complaints, findings, symptoms or treatment for photophobia during the Veteran's period of active service. Furthermore, although the Veteran received treatment for his eyes following the immersion burner explosion, the clinical records indicate that any injuries stemming from the in-service immersion burner explosion were acute and transitory and resolved within 24 hours. Indeed, the Veteran was deemed fit for duty the following day, the remaining service treatment records are negative for signs or diagnoses of an eye disability, and the subsequent clinical evaluations were negative for any visual problems. There is nothing in the record to indicate that the injuries resulting from the immersion burner explosion led to any permanent eye damage. Indeed, findings from the June 13, 1990 follow-up report reflect that the Veteran's eyelids were clear for any signs of swelling or redness, and the Veteran denied any pain or discomfort in the eyes. The Veteran was never diagnosed with having any type of eye disorder or eye problems after this in-service incident, nor did he complain of, or receive treatment for extreme sensitivity to the light following this in-service incident. In this regard, the Board notes that if the Veteran had been experiencing vision problems, and/or extreme light sensitivity, he had the opportunity to discuss his photophobia, and to report experiencing extreme light sensitivity during the June 1992 and February 2002 examinations but chose not to do so. It should be noted that a missed opportunity to report and seek treatment for eye problems weighs against the Veteran's current assertions. Indeed, there is nothing to show that the Veteran's photophobia began during his numerous periods of service in the Army National Guard, to include any period(s) of ACDUTRA and INACDUTRA. The Board finds the March 2012 VA examination, along with the June 2015 medical opinion issued by the VA optometrist, to be highly probative. The examination report in conjunction with the medical opinion are based on discussions with the Veteran regarding his medical history and current conditions, a complete review of the medical records, and a thorough physical examination. With respect to the opinion provided, the Board finds that the June 2015 VA optometrist provided a clear opinion concerning whether the Veteran's photophobia had its onset in, or was causally or etiologically related to his military service, including his periods of service in the Army National Guard. The VA optometrist based his opinion on the relevant medical evidence and offered a thorough rationale for the opinions reached that is supported by the evidence of record. Specifically, the June 2015 VA optometrist noted that the in-service immersion burner explosion did not cause or lead to any type of scarring in the corneal, iris or retinal area, and explained that such findings would have been expected had such an injury yielded lasting symptoms. He also relied on numerous eye examination reports which indicated that tinted glasses had been ordered for the Veteran's photophobia which was deemed secondary to his psychiatric medication. A number of the above-referenced eye examination and optometry reports did indeed relate the Veteran's photophobia to his psychiatric medication. Furthermore, review of the medical records in their entirety reflect the Veteran's diagnoses of, and treatment provided for, his depression, adjustment disorder with depressed mood and mood disorder. These records also list the various types of medication he had been prescribed with to help treat his psychiatric symptoms. Based on his review of the evidence, the June 2015 VA optometrist determined that the weight of the evidence reflected that the Veteran's photophobia was caused by the psychiatric medication he had been taking. In reaching this determination, the Board has also considered the lay statements of record. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997), Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991)("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, however, although the Veteran is competent to describe observable symptoms of photophobia, he is not competent to comment on the etiology of such disorders. Although a layperson can provide evidence as to some questions of etiology or diagnosis, the question of a medical relationship between a current diagnosed disorder and service, which would require more than direct observation to resolve, is not in the category of questions that lend themselves to resolution by lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). The Veteran is competent to report symptoms he experienced while in service and after service because such actions come to him through him senses and, as such, require only personal knowledge rather than medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran, however, is not competent to opine on the question of etiology and, therefore, his statements asserting a relationship between his current photophobia and his period of service do not constitute competent medical evidence on which the Board can make a service connection determination. Moreover, even if the Veteran's statements could be read as claiming continuity of symptomatology since service, the medical evidence of record discloses nearly twenty-one years from the time the Veteran was injured as a result of the June 1990 in-service immersion heater explosion and the first post-service medical evidence documenting his complaints of photophobia in January 2011. The record also discloses seven years from the Veteran's 2004 discharge from the Army National Guard and the first post-service documentation of the Veteran's photophobia. Furthermore, the record is clear for any clinical evidence to support any claim of in-service manifestations of photophobia with continuity of symptomatology thereafter. In any event, in the absence of any objective evidence to support his complaints of continuity of symptomatology in the years since service, the initial demonstration of the disability at issue nearly seven after his last period of service, to include any period of ACDUTRA and INACDUTRA, is too remote from service to be reasonably related to service and diminishes the reliability of the Veteran's current recollections. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). Moreover, with respect to any refractive error, the Board notes that for the purposes of entitlement to benefits, the law provides that refractive errors of the eye are developmental defects and are not diseases or injuries within the meaning of applicable legislation. In the absence of a superimposed disease or injury, service connection may not be allowed for refractive errors of the eyes even if visual acuity decreased in service, as this is not a disease or injury with the meaning of the applicable legislation relating to service connection. 38 C.F.R. § 3.303(c) . Accordingly, such disorders cannot be service-connected, absent evidence of aggravation by a superimposed disease or injury. See Monroe v. Brown, 4 Vet. App. 513, 514-515 (1993); Carpenter v. Brown , 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90 (July 18, 1990); VAOPGCPREC 82-90 (July 18, 1990); and VAOPGCPREC 11-1999 (Sept. 2, 1990). As indicated by the evidence, there is no basis to find that any current refractive errors are caused by, or a result of, or aggravated by superimposed disease or injury during service. In so finding, the Board relies on the June 2015 VA examiner's finding that there was no evidence of scarring in the corneal, iris or retinal area - something that would be expected to be present if such an injury occurred that would yield lasting system. Also, as discussed above, there was no apparent decrease or impairment in the Veteran's visual acuity following the in-service immersion burner explosion. Thus, to the extent that the Veteran may be claiming service connection for any current refractive error, he is not entitled to service connection for any refractive error as a matter of law. See 38 C.F.R. §§ 3.303(c), 4.9. For all the foregoing reasons, the Board finds that the claim for service connection for photophobia must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for photophobia is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran's claim for service connection for his headache disability. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. Similar to his claimed photophobia, the Veteran attributes his current headache disability to the in-service immersion explosion, which caused him to be thrown against a tree and knocked unconscious for a few minutes. Turning to the service treatment records, the Board notes that during a September 1984 consultation, the Veteran denied experiencing any headaches, numbness or tingling. Although the clinical records document the Veteran's in-service injury in June 1990 after an immersion burner exploded near his face, these records focus on complaints of, and medical treatment provided for, problems concerning his eyes, and are absent any complaints, findings or notations of headaches or neurological problems. At the June 1992 medical examination pursuant to the Veteran's enlistment into the Army National Guard, when asked about his current medication, the Veteran reported to take extra-strength Tylenol for his headaches. However, he did not complain of, or report to be experiencing any headaches at present, and he denied history of frequent or severe headaches, a head injury, memory loss of amnesia. The February 2002 physical examination was also negative for any neurological abnormalities. The post-service treatment records reflect that he began seeking treatment for his headache condition at the Lebanon VAMC in September 2010. During this treatment visit, the Veteran requested Tylenol for his aches/pains/headaches, and noted that had been told to stop taking Ibuprofen. At the February 2012 VA examination in connection to his claimed TBI (which he attributes to several in-service incidents - one of which is the immersion heater explosion) the Veteran specifically reported to experience residuals in the form of headaches, including migraine headaches, as a result of his TBI. The Veteran was afforded a separate examination for his headache disability in February 2012 as well, at which time he provided his medical history and described a two year history of headaches which start at the frontal sinus area and travel to the post cervical spine region. The Veteran described the headaches as constant and lasting "a couple of hours" in length. When asked whether the Veteran experienced headache pain, the examiner noted that he did, and described it as pain in the post cervical spine. The Veteran noted that the pain lasts less than one day and is located in the "post neck" area. Based on his discussion with, and evaluation of, the Veteran, the VA examiner diagnosed him with having tension headaches since approximately 2009. Pursuant to the May 2015 Board remand, the Veteran's claim was referred to another VA physician for an etiological opinion that addressed whether his headaches are related to his military service, to include the in-service immersion explosion that threw him into the air, knocked him onto a tree and rendered him unconscious momentarily. Based on her review of the records, the VA physician determined that the Veteran's headache condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In reaching this opinion, the VA examiner noted that based on her review of the VA treatment records, to include the neurology and pain clinic evaluations, as well as the electromyography (EMG) testing results, the current headache condition appeared to be related to the chronic neck/spine difficulties, and "it would be less likely as not...to attribute this to a military nexus based upon review of the records." Unfortunately, the Board finds the medical opinion to be somewhat unclear. In this regard, in concluding that the headaches "appeared" to be related to the chronic neck/spine difficulties, the VA opinion is lacking in certainty, and the VA physician appears to have relied on certain medical findings, while ignoring others. The Board acknowledges that the February 2012 VA examiner noted that the Veteran's headaches were predominantly located in the cervical spine region, and that the Veteran reported that his neck pain radiates into the back of his head and can develop into a migraine headache during the February 2012 VA consultation. However, during a number of VA treatment visits, the Veteran reported that his headaches start around his eyes and radiate towards the cervical spine region. Furthermore, at the February 2012 VA examination, the Veteran indicated that the headaches start at the frontal sinus area and travel to the post cervical spine region. These medical findings lead the Board to question whether the Veteran's headaches do in fact stem from his post cervical spine pain. The June 2015 VA physician appears to have relied on the medical findings suggesting that the Veteran's headaches stem from his cervical spine problems. However, in reaching this conclusion, he should also acknowledge the treatment records that serve to contradict or question these findings, and provide a more thorough explanation that reconciles these somewhat differing medical findings. Moreover, the Board is unclear as to whether a headache stemming or resulting from cervical spine problems predominantly originates in the spine, or whether it can also start near the frontal region of the head and radiate downwards. Furthermore, if the Veteran's headaches are due to his cervical spine condition/pain, is there a separate medical diagnosis for this particular condition, and if so, could this particular diagnosis be related to the Veteran's military service? As such, the Board finds that the VA physician should provide a more thorough and detailed medical opinion that addresses the differing medical findings. The VA physician should also reconcile the conclusion reached with any contradictory or inconsistent findings, and provide an explanation that applies the medical principles to the facts of the case. As such, the June 2015 opinion is of limited value because it is not predicated on a complete review of the Veteran's medical history. A medical opinion is considered adequate only "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl, 21 Vet. App. at 123 , quoting Ardison, supra. The opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions," id. at 124-25, and the "examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two," Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Thus, while there is no requirement imposed on a medical examiner to provide a statement of reasons or bases in support of his or her opinion, Ardison v. Brown, 6 Vet. App. 405, 407 (1994), the clinician must support his of her medical findings with adequate medical analysis. Stefl and Nieves-Rodriguez, both supra. As it remains unclear whether the Veteran's headache disability was incurred in service, another remand is necessary for another clarifying VA medical opinion. Accordingly, the case is REMANDED for the following action: 1. Obtain from the Lebanon VA Medical Center (VAMC) and Lancaster CBOC relevant records pertaining to treatment the Veteran has received for headache condition from April 2014 to the present time. All such available documents should be associated with the claims file, and all efforts to obtain the evidence must be noted it the claims folder. 2. Then, once these records have been obtained and associated with the claims file, refer the claims file to the same VA physician who provided the June 2015 medical opinion, for a clarifying medical opinion. If the requested VA physician is unavailable, then refer the claims file to another qualified VA physician. The claims folder, to include all records on VBMS and Virtual VA must be made available to the VA physician in conjunction with the examination. The VA physician should specifically take into consideration the February 2012 VA examination report indicating that the Veteran's headaches reportedly start at the frontal sinus area and travel to the post cervical spine region. Consideration should be given to the Veteran's history, and particularly to any statements regarding continuity of symptoms since service. If further examination is necessary, one should be scheduled Following a review of the record, the examiner should express an opinion as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that the Veteran's headache disability had its onset during his military service, to include the June 1990 in-service immersion heater explosion. If the VA physician concludes that the Veteran's headache disability was not incurred in service, but is rather due to and/or associated with his cervical spine condition, then he/she should provide a medical explanation for this conclusion, and reference the pertinent medical principles and theories as applied to the medical evidence in this case. The VA physician should also specify which, if any, records were relied upon in reaching his conclusion, and explain his/her decision to accord more probative weight to certain records as opposed to others. If the VA physician finds that the Veteran's headaches are due to his cervical spine disability, then he/she should address whether the Veteran may have a separate diagnosis for this type of disability, and if so, whether this disability could potentially be related to the Veteran's military service. The VA physician should also reconcile his/her conclusion with the medical evidence as a whole, and address any medical findings that contradict or call into question his/her conclusion and/or the medical records he/she relied upon. The VA physician must provide a thorough and well-reasoned rationale for all opinions provided. If the VA physician finds that the Veteran's headache disability is not related to his service, then he or she must provide a complete rationale upon which his or her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. If the VA physician determines that he/she cannot provide an opinion without resorting to speculation, the VA physician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). 3. Review the Veteran's claims file and ensure that the foregoing development actions have been completed in full, and that no other notification or development action, in addition to those directed above, is required. If further action is required, it should be undertaken prior to further claims adjudication. 4. Readjudicate the Veteran's claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. 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 or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs