Citation Nr: 1611472 Decision Date: 03/22/16 Archive Date: 03/29/16 DOCKET NO. 12-04 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for left hand Dupuytren's contracture, to include as secondary to a service-connected cervical spine disability. 2. Entitlement to a rating in excess of 0 percent for service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Casey, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1983 to September 1991. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a left upper extremity condition secondary to traumatic arthritis and denied a rating in excess of 0 percent for corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury. During the pendency of the appeal, a November 2011 rating decision granted a separate 20 percent rating for left upper extremity cervical radiculopathy, effective January 24, 2011. A June 2014 rating decision granted service connection for left ulnar neuropathy and left median neuropathy, rated 20 percent, effective January 24, 2011. The issue of service connection for left hand Dupuytren's contracture, to include as secondary to service-connected cervical degenerative disk disease remains on appeal, and was readjudicated by the RO in a May 2014 supplemental statement of the case. At his request, the Veteran was scheduled for a videoconference Board hearing in August 2015. The RO sent the Veteran a June 2015 letter notifying him of the date and time the hearing was scheduled; the RO's letter was subsequently returned as undeliverable with no forwarding address. As a result, the RO undertook to obtain the Veteran's current address and, in July 2015, sent him a copy of the June 2015 letter. The Veteran failed to appear for the hearing, and his hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d). The Veteran had also initiated an appeal of a denial of service connection for a right upper extremity condition secondary to a service-connected cervical spine disability, but he did not perfect the appeal following a November 2011 statement of the case. Consequently, that matter is not before the Board. FINDINGS OF FACT 1. The Veteran's left hand Dupuytren's contracture was not manifested until many years following service, and is not shown to be related to his service or to his service-connected cervical spine disability. 2. The Veteran's service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury has not been manifested by corrected distance vision worse than 20/40 in the left eye. CONCLUSIONS OF LAW 1. Service connection for left hand Dupuytren's contracture is denied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). 2. A higher rating is not warranted for the Veteran's service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.75, 4.76, 4.79, Diagnostic Codes (Codes) 6066, 6081 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A (West 2014) have been met. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). By correspondence dated in February 2011, VA notified the Veteran of the information needed to substantiate his claims, to include notice of the information that he was responsible for providing and of the evidence that VA would attempt to obtain, as well as how VA assigns disability ratings and effective dates of awards. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. He was afforded VA examinations in February 2011, February 2014, and March 2014, and addendum medical opinions were obtained in April 2014 and May 2014. The Board finds the examination reports and addendums, cumulatively, adequate for rating purposes, as they note all findings needed to adjudicate the claims. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide these matters, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board has reviewed the Veteran's entire record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection Claim Service connection may be granted for disability resulting from personal injury suffered or disease contracted during active military service, or for aggravation of a pre-existing injury suffered, or disease contracted, during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a disability there must be evidence of: (1) a present disability for which service connection is sought; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection is warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish secondary service connection for a disability there must be evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran's STRs, including an April 1989 periodic service examination and a service separation examination, are silent for any complaints, treatment, findings, or diagnosis of left hand Dupuytren's contracture. An August 1996 VA general medical examination report is silent for any complaints, findings, or diagnosis related to the left hand. September and November 1991 private treatment records from East Liverpool City Hospital show complaints of neck pain radiating into the left upper extremity with numbness of the left hand and fingers. An anterior cervical fusion was performed in November 1991. An August 1997 letter and treatment records from T.D., a private neurologist, indicate that the Veteran had persistent numbness and weakness of his left hand since his cervical fusion. It was noted that physical examination found weakness in the finger extensors. Cervical spine MRI revealed the left sided extradural defect of the cervical spine appeared to be due to a combination of disc herniation and osteophyte formation. VA treatment records note a diagnosis of left hand contracture since 2005. In September 2009, the Veteran reported numbness to the index finger and thumb since the cervical spine surgery in 1991. He described the onset as a knot in his hand that progressively worsened into the current condition. On physical examination, there was diminished range of motion of the 3rd and 5th digits, especially on flexion. The assessment was pain in the left hand 4th and 5th digits with Dupuytren's contracture of the 4th digit. In December 2009, the Veteran had surgery for release of left ring finger Dupuytren's contracture. Postoperatively there was residual proximal interphalangeal joint contracture. On February 2011 VA examination, it was noted that the Veteran had the stigmata of Dupuytren's contractures bilaterally and had undergone surgical repair. January 2012 VA treatment records note complaints of left hand pain and numbness from old contractures. In June 2012, physical examination found flexor contractor of the 4th and 5th digit of the left hand. On March 2014 VA examination, the Veteran reported onset of left hand finger contraction in 2009. The pertinent diagnosis was left hand Dupuytren's contracture. A May 2014 VA examiner's opinion indicates that the Veteran's Dupuytren's contracture is less likely than not proximately due to or the result of the Veteran's service-connected cervical spine disability. The examiner explained that based on a review of the medical records and medical literature, the left hand Dupuytren's contracture is less than likely permanently aggravated or a result of any event and/or condition that occurred and/or expressed in service and/or within one year of discharge, and was not caused by and/or worsened by an already service-connected cervical spine disability. Citing to medical literature, the examiner noted that the literature does not indicate the cervical spine has any etiology in the formation of Dupuytren's contractures. On January 2016 VA examination, muscle strength was 4/5 on left wrist flexion and dorsiflexion; there was full finger flexion and abduction. The Veteran is seeking service connection for left hand Dupuytren's contracture as secondary to his service-connected cervical spine disability. Although the Veteran's representative asserts that left hand Dupuytren's contracture had its onset during service and persisted, the evidence shows otherwise. The STRs are silent for any complaints, treatment, findings, or diagnosis related to left hand Dupuytren's contracture. A September 1991 private treatment record specifically found "full range of motion of the fingers . . . ." Post service treatment records note a diagnosis of Dupuytren's contracture since 2005 (13 years following service separation). A December 5, 2008, VA treatment note reported "left hand with contracture since 2005." That record indicated that the Veteran had not been medically treated since 2006. Accordingly, service connection on the basis that the Veteran's left hand Dupuytren's contracture manifested in service and persisted is not warranted. The only competent medical evidence of record is against the claim. The May 2014 VA examiner's opinion indicates that the Veteran's Dupuytren's contracture is less likely than not proximately due to or worsened by the Veteran's service-connected cervical spine disability, and is less than likely permanently aggravated or a result of any event or condition in service. As the examiner's May 2014 opinion reflects familiarity with the entire record and cites to medical literature that supports the conclusion, the Board finds it probative. Because there is no competent evidence to the contrary, the Board finds it persuasive. The Board has considered the Veteran's statements that relate his left hand Dupuytren's contracture to the service-connected cervical spine disability. However, as a layperson, he is not competent to provide an opinion regarding the etiology of a complex disease such as Dupuytren's contracture. He has not presented competent (medical opinion/textual) evidence in support of his theory that his Dupuytren's contracture is related to the service-connected cervical spine disability. Consequently, his opinion in this matter is not competent. In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for left hand Dupuytren's contracture, to include as secondary to a service-connected cervical spine disability; therefore, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The appeal must be denied. Increased Rating Claim The Veteran seeks a rating in excess of 0 percent for his service-connected left eye disability due to decreased vision. Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be assigned for periods of distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury has been rated 0 percent under 38 C.F.R. § 4.79, Code 6079. The Board notes that Code 6079 was amended effective December 10, 2008, and applies to claims filed on or after that date. See 73 Fed. Reg. 66543-54 (Nov. 10, 2008). From December 10, 2008, Diagnostic Codes 6061 - 6066 contain the criteria to evaluate impairment of central visual acuity. 38 C.F.R. § 4.79 (2015). The Veteran's increased rating claim for a left eye disability was received in January 24, 2011, thus the prior rating criteria are not applicable in the present appeal. The Board will thus consider the applicability of the amended rating. However, it is significant that while the RO assigned Code 6079 to the Veteran's left eye disability, the requirements of the rating criteria and the resultant analysis are the same, whether the rater applies the former or present rating criteria contemplating impairment of central visual acuity. The rating criteria contemplating diseases of the eye direct the rater to evaluate the disability on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. 38 C.F.R. § 4.79, Codes 6000-6009. The evidence does not show, nor has the Veteran asserted, incapacitating episodes related to his left eye disability during the current appeal period; and the rating criteria pertaining to such are thus not applicable in the present appeal. Id. There is no evidence of other eye disorders, including tuberculosis, retinal scars, glaucoma, neoplasms, nystagmus, conjunctivitis, ptosis, ectropion, entropion, lagophthalmos, loss of eyebrows, lids, or lashes, lacrimal apparatus disorders, neuropathy, cataract, aphakia, paralysis, pterygium, keratoconus, corneal transplant, or pinguecula. Thus, the rating criteria contemplating such are not applicable. 38 C.F.R. § 4.79, Codes 6010-6027, 6029, 6030, 6032, 6034-6037. Additionally, the evidence does not show that the Veteran has impairment of muscle function during the current appeal period, thus the rating criteria pertaining to such are not applicable in the present appeal. 38 C.F.R. § 4.79, Codes 6090, 6091 (2015). The evidence also does not show anatomical loss of both eyes, no more than light perception in both eyes, anatomical loss of one eye, and/or no more than light perception in one eye during the current appeal period; and the rating criteria contemplating impairment of central visual acuity for such, Codes 6061-6064 are thus not applicable in the present appeal. 38 C.F.R. § 4.79, Codes 6061-6064 (2015). Furthermore, Code 6065, contemplating impairment of central visual acuity with vision in one eye at 5/200, is not applicable, as there is no evidence of left eye vision impaired to that degree during the current appeal period. 38 C.F.R. § 4.79, Code 6065 (2015). Finally, Code 6080 does not apply, because the evidence does not show visual field defects such as homonymous hemianopsia, concentric contraction of the visual field, or the loss of half the temporal, nasal, inferior or superior visual fields. 38 C.F.R. § 4.79, Code 6080. Under Code 6081, a 10 percent (minimum) rating is warranted for unilateral scotoma affecting at least one-quarter of the visual field (quadrantanopsia) or with centrally located scotoma of any size. Alternatively, a scotoma of the left eye is rated based on visual impairment due to the scotoma, if that would result in a higher rating. Code 6066, contemplating impairment of central visual acuity with vision in one eye at 10/200 or better, is thus the most appropriate rating criteria in the present appeal. If visual impairment of only one eye is service-connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of rating visual impairment. 38 C.F.R. § 4.75. Central visual acuity should be rated on the basis of corrected distance vision. 38 C.F.R. § 4.76. Under Code 6066, a 10 percent rating is warranted for impairment of central visual acuity when corrected visual acuity is: (1) 20/100 in one eye and 20/40 in the other eye; (2) 20/70 in one eye and 20/40 in the other eye; (3) 20/50 in one eye and 20/40 in the other eye; or (4) 20/50 in both eyes. A 20 percent rating is warranted for impairment of central visual acuity when corrected visual acuity is: (1) 15/200 in one eye and 20/40 in the other eye; (2) 20/200 in one eye and 20/40 in the other eye; (3) 20/100 in one eye and 20/50 in the other eye; or (4) 20/70 in one eye and 20/50 in the other eye. Id. A 30 percent rating is warranted under Code 6066 for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 20/40 in the other eye; (2) 15/200 in one eye and 20/50 in the other eye; (3) 20/200 in one eye and 20/50 in the other eye; (4) 20/100 in one eye and 20/70 in the other eye; or (5) 20/70 in both eyes. A 40 percent rating is warranted for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 20/50 in the other eye; (2) 15/200 in one eye and 20/70 in the other eye; or (3) 20/200 in one eye and 20/70 in the other eye. Id. A 50 percent rating is warranted under Code 6066 for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 20/70 in the other eye; or (2) 20/100 in both eyes. A 60 percent rating is warranted for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 20/100 in the other eye; (2) 15/200 in one eye and 20/100 in the other eye; or (3) 20/200 in one eye and 20/100 in the other eye. Id. A 70 percent rating is warranted under Code 6066 for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 20/200 in the other eye; (2) 15/200 in one eye and 20/200 in the other eye; or (3) 20/200 in both eyes. An 80 percent rating is warranted for impairment of central visual acuity when corrected visual acuity is: (1) 10/200 in one eye and 15/200 in the other eye; or (2) 15/200 in both eyes. A 90 percent (maximum) rating under Code 6066 is warranted for impairment of central visual acuity when the corrected visual acuity is 10/200 in both eyes. Id. On February 2011 VA examination, the Veteran blurry distant and near vision in the left eye and poking pain, lasting for a second, about 3-4 times a month. Corrected central visual acuity of left eye near vision was 20/70- ; left eye distance vision is not noted. The impression was left eye pseudophakia with posterior capsular opacification, left eye nonaxial corneal scarring - not affecting vision, left eye posterior vitreous detachment, and question left eye axial refractive amblyopia. January and March 2012 VA treatment records show that the Veteran reported progressively worse vision over the last few years after having left eye cataract extraction in 2002. In March 2012, he underwent left eye laser surgery for a capsulotomy. Left eye distance visual acuity was 20/60 -2 without correction; corrected left eye distance visual acuity is not noted. An April 2012 VA treatment record notes that left eye distance visual acuity without correction was 20/50 -1; corrected left eye distance visual acuity is not noted. The left eye cornea had two small stromal scars. The impression was left eye pseudophakia, nonaxial corneal scarring, and very sensitive posterior vitreous detachment. It was noted that there was an unexplained decrease in vision of the left eye. Left eye posterior vitreous detachment was very sensitive but did not account for constant 20/40 bilateral visual acuity. On February 2014 VA examination, the Veteran reported blurred vision in the left eye only. The diagnoses were left eye central corneal opacity and pseudophakia. Corrected central distance visual acuity of both eyes was 20/40 or better. There was no anatomical loss, light perception only, extremely poor vision or blindness, or corneal irregularity resulting in severe irregular astigmatism. There were no incapacitating episodes attributable to the left eye disability. The functional impact on employment was unequal, reduced vision in the left eye at every task. It was noted that there was no visual field defect. A Goldmann perimeter chart shows that the visual field was less than the 40 degree threshold between the 0 and 30 degree meridians and the 345 and 360 degree meridians. An April 2014 VA addendum opinion indicates that the Veteran had cataract surgery to remove a presumed cataract intraocular lens, and the pseudophakia is a new and separate diagnosis. As discussed above, on February 2011 VA examination corrected central distance visual acuity of left eye was not noted. On February 2014 VA examination, his corrected central distance visual acuity of left eye was 20/40 or better. The right eye, as a non-service-connected eye, is considered as having corrected near and distance visual acuity of 20/40. 38 C.F.R. § 4.75. Where the corrected distance visual acuity is 20/40 in the left eye and 20/40 in the right eye, Code 6066 provides for a 0 percent rating. For a 10 percent or higher rating, the Veteran would need to show corrected distance visual acuity in the left eye of 20/70 or greater; such is simply not shown in the present appeal. The February 2014 Goldmann perimeter chart shows tracing of the visual field that indicates there was less than the 40 degree threshold between the 0 and 30 degree meridians and the 345 and 360 degree meridians. The Goldmann perimeter chart does not show that at least a quarter of the visual field is affected, or that there is a centrally located scotoma of any size. However, the Veteran's diminished visual field due to the scotoma may be rated based on visual impairment. See 4.79, Code 6081. Under 38 C.F.R. § 4.77, Figure 2, the Veteran's visual field, as traced on the February 2014 Goldmann perimeter chart, is to be rated as 20/40 visual acuity. Where the visual acuity is 20/40 in the left eye and 20/40 in the right eye, Code 6066 provides for a 0 percent rating. Therefore, the Veteran's service-connected left eye disability warrants a 0 percent rating under Code 6081. The Veteran asserts entitlement to a higher rating and is competent to report observable symptoms such as decreased visual acuity in the left eye. See Layno v. Brown, 6 Vet. App. 465, 471 (1994). However, there is no evidence that he has the knowledge, training, or skill to measure his own central visual acuity and determine that he has corrected distance visual acuity in the left eye at 15/200, or worse, such that a higher rating under Code 6066 is warranted. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In summary, the Veteran's service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury does not warrant a higher rating at any time during the appeal period. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b). See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Comparing the Veteran's service-connected left eye disability level to the applicable criteria, the Board finds that the degree of disability shown is encompassed by the rating schedule. This disability does not present an exceptional disability picture. The Veteran's report of decreased visual acuity in the eye is encompassed by the rating schedule. Therefore, referral of the claim for extraschedular consideration is not required. Finally, as the evidence does not show (nor is it alleged) that the Veteran's service-connected left eye disability renders him unemployable, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER The appeal seeking service connection for left hand Dupuytren's contracture is denied. The appeal seeking a higher rating for service-connected corneal scarring of the left eye with secondary induced irregular astigmatism and decreased visual acuity secondary to metallic foreign body injury is denied. ____________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs