Citation Nr: 1541625 Decision Date: 09/25/15 Archive Date: 10/02/15 DOCKET NO. 11-20 153 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for a left eye disability as a result of eye procedures performed by VA. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1960 to August 1963. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Portland, Oregon Department of Veterans Affairs (VA) Regional Office (RO). The matter was previously before the Board in November 2013 and February 2015, at which time it was remanded for additional development. A Board hearing was held before the undersigned in September 2012; a transcript is of record. The Board hearing was sufficient to fulfill his right to a hearing under 38 C.F.R. § 20.700(a). In August 2015, the Veteran requested that he be allowed to testify at another hearing before the Board. A new hearing may be warranted only upon a written motion based upon a sufficient cause, such as when "a hearing has not been recorded in whole or in part due to equipment failure or other cause, or the official transcript of the hearing is lost or destroyed." 38 C.F.R. § 20.717 (2014). The Veteran has not provided any cause for why he requests a second hearing, and the September 2012 hearing transcript is complete and of record. The Board finds no grounds to warrant scheduling a second hearing at this time. See 38 C.F.R. §§ 20.700, 20.703, 20.707, 20.717 (2014). FINDINGS OF FACT 1. On September 6, 2005, the Veteran underwent a VA laser photocoagulation procedure of the left eye to treat leaking blood vessels caused by proliferative diabetic retinopathy. 2. In June 2006, the Veteran began seeing blood in his left eye, and on June 16, 2006 was diagnosed with vitreous hemorrhage. He was treated with a vitrectomy procedure on January 22, 2007. 3. On April 17, 2007, the Veteran reported that he had lost sight in his left eye, and was diagnosed with left eye dense white cataract. 4. On May 2, 2007, the Veteran underwent removal of the cortical material and intraocular lens implant of the left eye. During the procedure, the lens fell into the vitreous cavity, and the Veteran was discharged to the Casey Eye Institute, where a vitrectomy and removal of the nuclear fragment was performed. 5. The Veteran's subsequent post-recovery evaluations have shown that he has mild left eye myopia which is correctable with eyeglasses to 20/20 vision. 6. The preponderance of the evidence reflects that the Veteran did not incur any additional left eye disability due to any VA medical procedures, treatment, or surgery, nor that any additional disability was incurred for which the proximate cause was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA employees or due to an event not reasonably foreseeable. CONCLUSION OF LAW The criteria for disability compensation pursuant to 38 U.S.C.A. § 1151 for a left eye disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 1151, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.361 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. 38 C.F.R. § 3.159(b)(1) (2014). VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, in a letter dated in January 2009, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim, including what information and evidence must be submitted by the Veteran and what will be obtained by VA. This notice also advised the Veteran of the specific elements required to establish service connection under 38 U.S.C.A. § 1151. The notice provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The case was last adjudicated in June 2015, and any defect as to timing of notice is harmless, non-prejudicial error. All relevant evidence necessary for an equitable resolution of the issue on appeal has also been identified and obtained, to the extent possible. The evidence of record includes the reports of a VA examination and several addenda, the Veteran's VA and private treatment records, lay statements, and the transcript of the September 2012 Board hearing. The Board previously remanded this issue in November 2013 and February 2015 for further development. As was requested in the prior remands, all updated VA treatment records have been obtained and associated with the claims file, including consent forms. Additional VA addendum opinions were obtained, and the Board finds that together, these opinions show substantial compliance with the prior remand instructions, including the necessary responses to all questions posed for the VA examiner. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). These VA opinions are adequate for evaluation purposes, and no further examinations or opinions are necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007). All new evidence of record was reviewed prior to the issuance of the June 2015 supplemental statement of the case. The Board therefore concludes that there was substantial compliance with the Board's prior remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran also was provided an opportunity to set forth his contentions during the September 2012 Board hearing. Veterans Law Judges have a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the Board hearing, the undersigned set forth the issue to be discussed, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help 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) (2014) during the hearing, nor have they identified any prejudice in the conduct of the hearing. Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claim. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Background The Veteran testified at a September 2012 Board hearing that spotting and leakage was found in his left eye when they were being checked due to diabetes at either the Roseburg or Portland VA Medical Center. Board Hearing Tr. at 4-5. He stated that students, not doctors, lasered his eye and at first it did not affect his vision. Id. at 5-6. Then later, he had a "big flash" in one eye, and a few days after that he lost vision in the eye, which turned red and had blood "running down" it. Id. at 6. He went in for more lasering, but after he got home, his eye became full of blood, and he was told he would have to wait for it to dissipate before he could have more surgery; during this time, he was blind for seven months and could not work. Id. at 7. He went in again for them to "drain" his eye, and a week after that he was told he had a cataract and would need more surgery. Id. at 8. He reported there were delays in getting an appointment for the cataract surgery, and that after he finally received surgery at VA, he was rushed to Casey Eye Clinic for further procedures Id. at 10-11. He also testified that he believed it said in his records that it was either negligence or a mistake of some sort that resulted in something falling in his eye during the cataract surgery. Id. at 11-12. He stated that he did sign a waiver/consent form before every procedure, but that he did not read them because he trusted the doctors and "probably couldn't understand the waiver anyway." Id. at 15-16. The Veteran's VA treatment records show extensive treatment related to diabetic retinopathy in both eyes. The Veteran attended a VA optometry consultation for the first time in August 2003 after being diagnosed with significant diabetic retinopathy. He denied any vision complaints. The Veteran had 20/20 visual acuity and was diagnosed with moderate to severe nonproliferative diabetic retinopathy without clinically significant macular edema. In February and September 2004, the Veteran had follow-up visits for diabetic retinopathy. He denied any vision complaints and was found to have severe nonproliferative diabetic retinopathy without clinically significant macular edema. He was noted to have large cotton wool spots with associated hemorrhages. In July 2005, the Veteran had a follow-up treatment of severe left eye nonproliferative diabetic retinopathy. He reported having vision that was a little blurry both at distance and near for the last several months. He was found to have good vision without correction, with hemorrhages and spots. He was diagnosed with left eye clinically significant macular edema and possible proliferative diabetic retinopathy. In August 2005, the Veteran underwent a left eye fluorescein angiography, and on September 6, 2005, the Veteran was treated with laser photocoagulation of the left eye. An August 2005 signed consent form for photography and fluorescein angiography of the eye and a September 6, 2005 signed consent form for focal/grid laser photocoagulation of the left eye to close leaking blood vessels are of record. The September form notes that leakage causes swelling of the macula and that laser treatment reduces the risk of vision loss. The treatment record indicates that the September procedure was performed by an ophthalmologist. In May 2006, the Veteran reported seeing flashes of light when startled, and he was diagnosed with severe nonproliferative diabetic retinopathy and presurgical cataracts. On June 16, 2006, the Veteran had a VA optometry consultation at the Roseburg VA Medical Center at which he reported new onset loss of vision in his left eye which had occurred on June 2. He saw red, brown, and lines that swirl, and he was noted to have a history of diabetes. Examination found clear cornea and media opacity, and he was diagnosed with new vitreous heme left eye. He was noted to be already scheduled for a posterior vitreous detachment retina in July. That same day, the Veteran also went to a follow-up examination at the Portland VA Medical Center, at which he reported having "blood in the eye" which started on June 3, along with decreased vision. The Veteran was diagnosed with proliferative diabetic retinopathy with vitreous hemorrhage. On July 6, 2006, the Veteran reported not being able to see with the left eye since early June when it filled from hemorrhage. The ophthalmologist found that they should wait for 3 weeks, or possibly treat the eye with a laser earlier if his vision cleared. On September 26, 2006, the Veteran was seen for chronic vitreous hemorrhage at the Casey Eye Institute. Progress notes from September 27, 2006 note that the Veteran was treated the day before for a vitreous hemorrhage which was presumably diabetic in etiology. On December 8, 2006 and January 19, 2007, the Veteran was evaluated for a non-clearing left eye vitreous hemorrhage which had its onset on June 1, 2006. A B-scan from September 2006 showed dense vitreous hemorrhage and attached retina. The Veteran and his wife attended a surgery preoperative assessment in January 2007, and the Veteran verbalized knowledge of the surgical and anesthetic procedures preoperatively. Signed consent forms dated January 19, 2007 for an injection of medication into the eye to treat proliferative diabetic retinopathy and dated January 22, 2007 for removal of blood in the eye due to vitreous hemorrhage are of record. On January 22, 2007, the Veteran underwent a vitrectomy/MP/silicone oil removal procedure. On January 23, 2007, the Veteran returned for a day 1 status-post procedure follow-up. The retina fellow indicated that the Veteran was doing well. On January 30, 2007, the Veteran returned for a post-operative visit. He reported that he bumped his eye and had some threads in his vision. Visual acuity was 20/400. The sclera was found to be healing well. On February 20, 2007, the Veteran reported for a post-operative visit stating that his eye teared profusely and had no change in vision. His vision was found to be 20/200. The lens was found to be phakic, with sclera healing well. The examiner noted at these visits that the Veteran would need cataract extraction and intraocular lens performed, but that he should wait until 3 months since that last procedure. On April 17, 2007, the Veteran reported that his left eye visual acuity had gotten worse and that he couldn't "see anything out of it anymore," which prevented him from being able to work. His left eye visual acuity showed that he could count fingers at a distance of 1 foot, and he was diagnosed with a sense white cataract. On April 30, 2007, consent for cataract extraction with intraocular lens was obtained, scanned, and attached to the treatment record by a patient services assistant. It was noted that it was dated and properly signed by the patient and appropriate provider. Physical examination by an ophthalmology resident found that the Veteran had left eye surgical cataract, and visual acuity showed that he could count fingers at a distance of 5 feet. An April 30, 2007 signed informed consent form for removal of natural lens and replacement with artificial lens is of record. On May 1, 2007, at a surgery preoperative assessment with a surgical nurse, the Veteran verbalized knowledge of the surgical and anesthetic procedures preoperatively. The Veteran's wife was also present. On May 2, 2007, the Veteran underwent removal of the cortical material and intraocular lens implant. His preoperative diagnosis was left eye white cataract after vitrectomy. The findings were of a white cataract, nonintact posterior capsule. Hydrodissection was performed, and it was noted that the entire lens fell to the vitreous cavity. Residual cortical material was removed using irrigation/aspiration, and the wound was closed. The retinal fellow physician was called and it was agreed that the patient should be transported to Casey Eye Institute for possible lensectomy. It was noted that the complications were posterior capsule opening with lens in vitreous cavity. The Veteran was discharged in good condition. The treatment record notes that a scanned informed consent document was attached to the treatment record. It was noted to be dated and properly signed by the patient and appropriate provider. The record contains an anesthesia signed consent form dated May 2, 2007, which indicates that the procedure, the use of sedation, the indications, risks, benefits, and alternative treatments were explained, and that the patient was offered an opportunity to ask questions and consented freely. A May 2, 2007 postoperative report from Oregon Health and Science University Casey Eye Institute shows a preoperative diagnosis of retained lens/nuclear fragments in the left eye, and a pars plana vitreotomy and lensectomy of the left eye was performed. Treatment notes stated: The patient has a history of proliferative diabetic retinopathy. He has undergone vitrectomy previously for nonclearing vitreous hemorrhage in his left eye. His cataract progressed to a dense white opaque cataract and he underwent scheduled phacoemulsification this morning. However large fragments of the nucleus (nearly the entirety of the nucleus) fell through the posterior capsule into the vitreous cavity. An intraocular lens was placed during that previous surgery. The patient was then referred to our service for vitrectomy and removal of the nuclear fragment. The surgery was completed with no complications. At a May 3, 2007 post-operative visit, the Veteran was noted to be status post surgery for retained lens fragment. The patient slept well with no significant pain. There was good panretinal photocoagulation pattern in the periphery. On May 8, 2007, the Veteran's left eye was found to have clear cornea, lids with appropriate edema, and conjunctiva well closed. It was found that he had well-treated proliferative diabetic retinopathy. He was found to be doing well with edema. He was diagnosed with vitreous hemorrhage. On May 10, 2007, the Veteran was seen for a follow-up, and found to have macular edema, but was noted to be doing well. On May 22, 2007, the Veteran was treated for diabetic macular edema, and the fluorescein angiography procedure was noted to have been performed without complication. Informed consent was received by his ophthalmologist for laser treatment of the retina to treat leaking blood vessels damaged by diabetes. A May 22, 2007 signed consent form for retina-laser for macular edema to treat retina swelling caused by diabetes is of record. The listed known risks include blind spots, failure to control swelling, loss of central vision, macular pucker, corneal abrasion, and development of new vessels at laser site. The form is also signed and witnessed by his wife. On June 29, 2007, an ophthalmology fellow found left eye temporal thickening, and the Veteran stated that his left eye visual acuity had gotten worse and was unable to pass his driving test. His left eye vision was 20/100, and he was found to have well-treated proliferative diabetic retinopathy with macular edema and temporal thickening with a small amount of lipid. On July 27, 2007, the Veteran had a follow up examination. He reported bad visual acuity. Macular edema was present with temporal thickening and a small amount of lipid. He was found to have temporal edema and it was noted that it was too soon for more aggressive intervention given the recent focal laser treatment. It was also noted that epiretinal membrane was "probably playing a role in edema," and the Veteran noted that his blood sugar was "running around 110." In September 2007, the Veteran was found to have left eye visual acuity of 20/70, and in February 2008, the Veteran reported that the left eye was blurry at a distance, but that he could see well to read. The Veteran was found to have 20/80 visual acuity in the left eye, with a flat healthy retina with no tears or holes. The Veteran was assisted in ordering eyeglasses. On June 17, 2008, the Veteran returned for a follow up for treated proliferative diabetic retinopathy, pseudophakia, and clinically significant macular edema. He was noted to be doing well with good vision with the left eye corrected. Examination found a left eye flat healthy retina with no tears or holes. The patient was not happy with refractive error, but saw well with glasses. At a November 2008 eye consultation, the Veteran was found to have 20/20 corrected visual acuity, with a prescription of -1.25/-.75 in the left eye. The cornea had a temporal clear incision, with one remaining temporary suture. He was found to have improved left eye vision, pseudophakia, and mild Fuch's. Subsequent eye examinations continued to show similar visual acuity in the left eye. In May 2009, he reported that he was unhappy with how his vision had turned out after the treatment for diabetic vitreous hemorrhage because he did not have clear and equal vision without glasses. He stated that "his vision is fine and he's functional with it when wearing the glasses." The examiner related to the Veteran that 20/20 vision with correction was a "best-case outcome given his degree of diabetic eye disease and the complicated clinical and surgical course that he has undergone." The Veteran underwent a VA examination in December 2009 with an ophthalmologist. The Veteran reported that he never had any serious problems with his eyes until he needed reading glasses, and then in 2006 he was found to have some leakage in the left eye and was recommended for laser treatment. He stated that after the laser treatment at Portland VA Medical Center, he had some flashes of light, and then after several more treatments, his left eye began to fill with blood. His vision became very poor, and was told to wait 3 months to have a cataract removed. He stated that on return, he was again made to wait for surgery, and during the surgery a portion of the lens went into the vitreous cavity, requiring lens implant. After the surgery, his distance was very blurry, and that the Portland VA Medical Center has not corrected the problem. The Veteran reported having a loss of depth perception, which prevented him from operating machinery with uncorrected eyes. The Veteran felt that he lost his job because he could not work while his eye was "'full' of blood," and that after his eye was treated, his job ceased to exist. On physical examination, the examiner found slightly irregular and contracted vision in the left eye and diagnosed the Veteran with diabetes mellitus with proliferative diabetic retinopathy, and left eye status post panretinal photocoagulation, vitrectomy, cataract extraction, and removal of retained lens material in the vitreous. An optometrist provided a VA medical opinion in March 2010 after reviewing the claims file. He discussed the results of the prior VA examination, and stated that the Veteran had extensive panretinaphotocoagulation in the left eye necessitated by diabetic retinopathy, which can cause reduced peripheral vision. His Goldman visual field did suggest slight decrease in peripheral vision. He stated that both the edema and the treatment have the potential to reduce best corrected visual acuity, but since he could presently see 20/20 with eyeglasses, it did not appear that he suffered vision loss from the disease or the treatment. An addendum VA medical opinion was obtained in March 2014 from the examiner who performed the 2009 VA examination. He reviewed all available records, and stated that the Veteran had 20/20 vision in each eye before the procedures began, and still has 20/20 vision, but requires a mild near-sighted correction. He explained that the Veteran's left eye went through multiple procedures because his "diabetic retinal disease had entered a devastating stage, and permanent blindness would have resulted without these interventions. These treatments worked with the end result of 20/20 vision in the left eye with mild myopia, a mild refractive error." He wrote that all procedures were necessary and done in a timely manner, the indications, reasoning, and procedures were well documented, and no faults were found. A follow up VA opinion was obtained in October 2014, also from the examiner who performed the December 2009 eye examination. After reviewing all available records, he found that it was less likely than not that the Veteran incurred additional left eye disability as a result of VA medical care. He noted that the Veteran did not have a disability, as he was mildly near-sighted and had 20/20 vision with the use of glasses. He stated that the Veteran was "essentially blind when the surgical procedures began," and now has 20/20 vision after the procedures, and therefore additional disability was not incurred. He wrote that the Veteran "had proliferative diabetic retinopathy, an advanced diabetic retinopathy that usually irrevocably blinds an eye left untreated." This meant that the procedures he underwent were necessary in order to avoid the risk of losing all useful vision, and that the ability to correct this condition to 20/20 vision with mild myopic correction was "remarkable." He also noted that the 2005 and 2006 procedures were "fluorescein angiograms and laser procedures," which are not actual operations. The examiner also found no "instance of carelessness, negligence, lack of proper skill, error in judgment, or similar event" and that "mild myopia/nearsightedness was a foreseeable risk as it is with all cataract surgeries and could not have been avoided with better diligence, skill, judgment, etc." An additional VA addendum opinion was obtained from the same examiner in May 2015. After reviewing all available records, he stated that the Veteran's visual acuity did not worsen as a result of the May 2, 2007 surgery, including due to the "foreign objects" retained in the eye, as his vision prior to this surgery was "virtually nil," and he regained 20/20 vision after the surgery. He also explained that the Veteran's vision did not worsen due to his eye procedures and that mild myopia was not considered a disability or an additional disability, and went on to explain why a replacement lens may result in mild myopia. He stated that there was no worsening due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. The Veteran also submitted a private medical evaluation from August 2011. The Veteran asked the examiner to evaluate his eyes to determine if he felt that the laser surgery he received had ruined his peripheral vision. The Veteran reported that he had loss of peripheral vision in his left eye. The examiner diagnosed the Veteran with visual field defects in the periphery of both eyes from prior laser therapy from proliferative diabetic retinopathy which were "an expected outcome of the surgery." He stated that he could not speak as to whether VA "performed too much" surgery, as the quantity would depend upon the amount of retinopathy present at the time. He also found that the Veteran had bilateral chorioretinal scars, which were an expected outcome of the surgery, and that his vision was 20/20- in the left eye. III. Analysis The Veteran contends that he has additional disability of the left eye, manifested by loss of peripheral vision and visual acuity, which was caused by VA negligence while performing his eye procedures and surgery in 2005, 2006, and 2007. In addition to the assertions made at the September 2012 Board hearing discussed above, the Veteran has also submitted a written statement in April 2010 contending that he believes VA errors resulted in the need for multiple surgeries and that he had 20/20 vision prior to his surgery, and this visual acuity level has not been restored. In an August 2015 statement, the Veteran wrote that he believes VA did not provide adequate and timely care, and that the delay in getting surgery for his eye after it filled with blood was the cause of his eye disability. Under 38 U.S.C.A. § 1151, compensation shall be awarded for a qualifying additional disability of a veteran in the same manner as if such additional disability were service connected. A disability is a qualifying additional disability if it was not the result of the veteran's willful misconduct and either: 1) the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a VA employee or in a Department facility, and the proximate cause of the disability was either A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or B) an event not reasonably foreseeable; or 2) the disability was proximately caused by the provision of training and rehabilitation services by the Secretary as part of an approved rehabilitation program. 38 U.S.C.A. § 1151 (West 2014). The first element of a claim under 38 U.S.C.A. § 1151 is whether the Veteran has an additional disability as a result of VA care or treatment. See 38 C.F.R. § 3.361. If an additional disability is present, the issue then becomes whether the VA procedure actually caused the additional disability. Id. However, causation alone is not sufficient to warrant compensation under 38 U.S.C.A. § 1151; rather, the evidence must show either that the additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination; or that it was an event that was not reasonably foreseeable. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and either (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. 38 C.F.R. § 3.361(d)(1). For the following reasons, application of the law to the above facts warrants denial of the claim for entitlement to compensation benefits under 38 U.S.C.A. § 1151 for a left eye disability. The first element required to establish a claim under 38 U.S.C.A. § 1151 is the existence of an additional disability as a result of VA care or treatment. To determine whether the Veteran has an additional disability, VA compares his condition immediately before the beginning of the surgical treatment to his condition after such treatment has stopped. 38 C.F.R. § 3.361(b) (2014). In this case, the Veteran has variously contended that he believes it was either the surgery he underwent on May 2, 2007 at which an act of negligence occurred or that it was his entire course of treatment at VA, starting with the September 6, 2005 laser photocoagulation and all subsequent treatments that, cumulatively, were not administered in an adequate and timely fashion. Regarding the assertion that an act of negligence occurred during the May 2, 2007 surgery, the Board finds that the Veteran clearly had no additional disability following the surgery compared to his state before the surgery. As is amply recorded in the treatment records and was noted by the VA examiner in May 2015, the Veteran's vision prior to this surgery was "virtually nil," with prior examinations showing that he could count fingers only at 1 or 5 feet, and after recovering from the surgery, he regained 20/20 vision, with corrective lenses. Even without corrective lenses, his vision is improved beyond where it was before the May 2, 2007 surgery. The Veteran has also asserted that the negligence occurred throughout the entire course of his treatment, and that he was given both too much laser treatment on his left eye and that the treatment he received for his vitreous hemorrhages was not done in a timely manner. In that respect, the Board looks at whether the Veteran incurred additional disability compared to the condition of his left eye prior to September 6, 2005. By July 2005, the Veteran's diabetic retinopathy was being closely monitored, and he reported having blurry vision and was found to have hemorrhages and spots in his vision. He was diagnosed with left eye clinically significant macular edema and possible proliferative diabetic retinopathy. The September 6, 2005 procedure was recommended in order to close leaking blood vessels in the eye. The VA examiner wrote in March 2014 that the Veteran's diabetic retinal disease had "entered a devastating stage, and permanent blindness would have resulted without these interventions," and he further wrote in October 2014 that the Veteran had "proliferative diabetic retinopathy, an advanced diabetic retinopathy that usually irrevocably blinds an eye left untreated." The ability of the Veteran's treating medical professionals to repair his vision to 20/20 vision with correction was "remarkable," and pointed out that mild correctable nearsightedness was not a disability. The Board therefore finds that the Veteran's mild decrease in uncorrected visual acuity does not constitute an additional degree of disability, as the overall condition of the Veteran's eyes since before the procedures had significantly improved. The Veteran submitted a private August 2011 examination in which the examiner found that there were also visual field defects in the periphery of both eyes due to laser therapy. Although this is not clear evidence that the Veteran incurred "additional disability," as the Board still finds that the condition of the Veteran's left eye was significantly better following the VA procedures than it was beforehand, even if the Board were to accept this as an incurred disability, the second element required to establish a claim under 38 U.S.C.A. § 1151 has not been shown by the evidence of record. The evidence must show either that the additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA; or that it was an event not reasonably foreseeable. 38 U.S.C.A. § 1151. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault, it must be shown that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that VA failed to obtain the veteran's informed consent. 38 C.F.R. § 3.361(d)(1) (2014). The evidence of record shows that the Veteran provided informed consent before his first laser photocoagulation treatment in September 2005, before his procedure on January 22, 2007, before his cataract extraction on April 30, 2007, and before his surgery on May 2, 2007. The Veteran also testified in September 2012 that he did sign a waiver/consent form before every procedure. Board Hearing Tr. at 15-16. There is also no indication in the record that there was any instance of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault due to VA's failure to exercise the degree of care that would be expected of a reasonable health care provider or that the event was not reasonably foreseeable. The most probative opinions of record are those of the VA examiner who provided the December 2009 examination and 2014 and 2015 addendum opinions. This examiner is a qualified ophthalmologist who examined the Veteran in person and reviewed all of the evidence of record. After reviewing the records pertaining to the Veteran's surgery, he found that all of the procedures performed were necessary and done in a timely manner, all of the procedures were well documented, and no faults were found. He found no instance of carelessness, negligence, lack of proper skill, error in judgment, or fault, and stated that the Veteran's slightly decreased uncorrected visual acuity "was a foreseeable risk as it is with all cataract surgeries and could not have been avoided with better diligence, skill, judgment, etc." The examiner explained at length why mild myopia is an expected result of replacing a lens. The examiner thoroughly addressed the Veteran's contention and provided adequate rationale for his finding. As the examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The private opinion submitted by the Veteran also weighs against the claim. While this examiner, unlike the VA examiner, found that the Veteran did have an additional disability, specifically loss of peripheral vision in the left eye, he also found that such a visual field defect was "an expected outcome of the surgery." He stated that because the number of procedures required would depend on the severity of the Veteran's retinopathy, he could not opine on whether VA had performed more surgery than necessary, as the Veteran has contended. There is no contrary medical opinion in the evidence of record. The Board must also consider the lay evidence. Lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's testimony as to the relationship between his eye procedures and surgery and any loss of visual acuity or visual field defects is testimony as to an extremely complex internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). To the extent that the Veteran is competent to offer an opinion on this complex medical question, or to the question of whether he currently has a disability which constitutes a worsening of the condition of his eyes compared to their state prior to the procedures, the specific, reasoned opinions of the VA ophthalmologist examiner are of greater probative weight than the Veteran's more general lay assertions. In sum, the preponderance of the evidence of record reflects that the Veteran did not incur an additional disability as a result of VA care or treatment; that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA; and that there were no complications from treatment that were reasonably foreseeable. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim for entitlement to compensation for a left eye disability pursuant to 38 U.S.C.A. § 1151 is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2004); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for a left eye disability as a result of eye procedures performed by VA is denied. ____________________________________________ Donnie R. Hachey Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs