Citation Nr: 1630234 Decision Date: 07/28/16 Archive Date: 08/04/16 DOCKET NO. 10-28 729 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for a right eye disability. 3. Entitlement to service connection for a back disability, to include as secondary to service connected knee and foot disorders. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Amanda Baker, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1966 to September 1968 with additional service in the Army Reserve. These matters come before the Board of Veterans Appeals (Board) on appeal from a February 2010 rating decision of the Regional Office (RO) in Waco, Texas, which denied service connection for right and left eye disorders, bilateral hearing loss, bilateral foot disorder, and a back disorder. As for a left eye disorder, in January 2014 the Board denied the Veteran's claim for entitlement to service connection for a left eye disorder, and remanded the remaining claims on appeal for further development, to include outstanding Army Reserve service personnel records and to afford the Veteran a VA examination to determine the nature and etiology of his back disorder. As for a bilateral foot disorder, in a July 2014 rating decision the RO granted service connection for bilateral pes planus (a foot disorder) and assigned an evaluation of 10 percent. The Veteran did not timely appeal the initial rating assigned. The Board finds that this grant of service connection constitutes a full award of the benefits sought on appeal with respect to that issue. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). The issues of entitlement to service connection for a right eye disability and back disability are addressed in the REMAND portion of the decision below and are REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. Left ear hearing loss disability did not manifest in service, within the one year presumptive period, or for many years after service, and is unrelated to in-service noise exposure. 2. Right ear hearing loss disability noted on preinduction examination did not worsen during service. CONCLUSIONS OF LAW 1. A left ear hearing loss disability was not incurred in or aggravated by service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2015). 2. Right ear hearing loss disability noted on preinduction examination was not aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1153, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.307, 3.309, 3.385 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The VCAA applies to the instant claims. VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In reference to the claim for entitlement to service connection for hearing loss, VA has fulfilled the above requirements. In a March 2009 VCAA notice letter the Veteran was duly informed of the evidence needed to establish service connection. The issue was last readjudicated in a July 2014 Supplemental Statement of the Case. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist a claimant in the development of a claim. This duty includes assisting in the procurement of service treatment records and all relevant pre-and post-service treatment records, and by providing an examination, when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished in this case, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Reasonable efforts were made to obtain all private and VA treatment records identified by the Veteran. The Veteran's service treatment records, personnel records, private and VA treatment records, and lay statements of the Veteran and others have been obtained and associated with the claims file. The AOJ made numerous attempts to obtain all identified records, including VA treatment records. The Board finds that all reasonable efforts to obtain outstanding treatment records were made. There is no indication that further pertinent medical records were not appropriately requested, or that records received were not appropriately associated with the claims file. This case was previously remanded in January 2014. The Board finds that all prior remand instructions pertinent to the service connection claim for hearing loss have been adequately completed. Pursuant to the January 2014 remand, outstanding Army Reserve records are associated with the claims file. The Board therefore finds that there has been substantial compliance with the remand directives with regards to the hearing loss service connection claim. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). In sum, the Board finds that VA has complied with the VCAA's notification and assistance requirements, and any error in notice and development assistance cannot "reasonably affect the outcome of the case," and hence will not affect "the essential fairness of the [adjudication]" for the service connection claims at issue. See ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998); Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Hearing Loss As an initial matter, there is no evidence of argument that the Veteran engaged in combat with the enemy. His service personnel records, to include his DD Form 214, do not indicate that the Veteran engaged in combat (e.g., no combat awards or decorations). Therefore, the combat provisions of 38 U.S.C.A. § 1154(b) (West 2014) are not applicable. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Consistent with this framework, service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system such as sensorineural hearing loss, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1); 38 C.F.R. §§ 3.307(a) , 3.309(a). See also Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995 (sensorineural hearing loss is an organic disease of the nervous system). The Veteran contends that he developed hearing loss due to in-service noise exposure. See July 2012 Correspondence. He claims that basic training did not provide him with ear plugs which caused current bilateral hearing loss. Id. In addition, he claims that he was exposed to military noise exposure, to include gun discharge, truck noise, and generator noise without wearing hearing protection. See July 2009 VA Examination Report. The Veteran's DD-214 reflects that his military occupational specialty was a heavy vehicle driver. Hence, the Board finds that in-service acoustic trauma is consistent with the circumstances of the Veteran's service. 38 U.S.C.A. § 1154(a). For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When audiometric test results at separation from service do not meet the regulatory requirements for establishing a "disability" at that time, a veteran may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The threshold for normal hearing is from 0 to 20 decibels. Id. at 157. In this case, based on the December 2009 VA examination, the Board finds that the Veteran has a current diagnosis of bilateral hearing loss for VA purposes. See 38 C.F.R. § 3.385. The Veteran has therefore met the current disability element. As noted, the in-service injury or event element has also been met by the conceded noise exposure and acoustic trauma. Therefore, the only issue remaining on appeal is whether current hearing loss is related to the in-service noise exposure. An audiological evaluation during the Veteran's military service took place prior to October 31, 1967. Based on knowledge of service audiometric practice, it is assumed that service department audiometric tests prior to this date were in ASA (American Standard Association) units, and require conversion to ISO units. The ASA units generally assigned lower numeric scores to hearing loss than do the ISO (International Organization for Standardization) units. Conversion to ISO units is accomplished by adding 15 decibels to the ASA units at 500 Hertz, 10 decibels to the ASA units at 1000 Hertz, 2000 Hertz, and 3000 Hertz, and 5 decibels to the ASA units at 4000 Hertz. See VA Interim Issues 21-66-16, 21-66-17 (June 6, 1966); 10-66-20 (June 8, 1966); DM&S Manual M-2, Part XVIII, Chapter 4, paragraph 4.02, Use of International Standards Organization (ISO) for Audiological Examinations. In the audiometric tables below, ASA units are indicated in parentheses. An audiological evaluation conducted as part of the Veteran's March 1966 pre-induction examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5(20) -5(5) -5(5) 40(50) 35(40) LEFT 5(20) -5(5) -5(5) -5(5) 15(20) An audiological evaluation conducted as part of his August 1968 separation examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5(20) -5(5) -5(5) X 35(40) LEFT 5(20) -5(5) -5(5) X 0(5) The Board notes that the Veteran had the same hearing threshold at induction and separation. See July 2009 VA examination. Thus, although the August 1968 audiological examination is after October 31, 1967, the date that audiometric tests were converted from ASA units to ISO units, it appears that the August 1968 audiometric test was still conducted in ASA units. As such, the August 1968 separation examination reflects conversion to ISO units. Post-service, the Veteran was afforded a VA audiological evaluation in July 2009 that revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 50 55 75 55 55 LEFT 20 20 15 55 55 Speech recognition scores were 88 percent for the right ear, and 96 percent for the left ear. As such, these results indicate that the Veteran has a bilateral hearing disability for VA purposes. See 38 C.F.R. § 3.385. The examiner diagnosed bilateral sensorineural hearing loss. The examiner indicated that she could not review the claims file, and thus could not provide an opinion on the etiology of the bilateral hearing loss disability without resorting to speculation. In a subsequent July 2009 addendum, based on a review of the claims file, the same examiner opined that it was less likely than not (less than 50 percent probability) that bilateral hearing loss was caused by or a result of an event in military service. As rationale, the examiner stated that service treatment records show no change in hearing during service. At the March 1966 pre-induction examination, the Veteran had mild hearing loss in the right ear at 3000-4000 Hertz and normal hearing in the left ear. At the August 1968 separation examination, the Veteran had mild hearing loss in the right ear at 4000 Hertz and normal hearing in the left ear. The examiner acknowledged that at the pre-induction examination the Veteran had right ear hearing loss at 3000 Hertz; however, at separation an evaluation at 3000 Hertz for the right ear was not conducted. The July 2009 examiner's opinion explicitly acknowledged the Veteran's report of hearing loss in the years since service. This opinion is based upon a review of medical records, reported history, and is accompanied by a specific rationale that is not inconsistent with the evidence of record. In this this regard, the Board notes that the examiner acknowledged that the Veteran had some level of decreased hearing acuity at pre-induction that remained the same at separation. Thus, this opinion is adequate and 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; threshold considerations are whether the person opinion is suitably qualified and sufficiently informed). Additionally, the claims file contains post-service treatment records showing complaints of hearing loss. February 2009 private treatment records show complaints of hearing loss affecting daily function. On physical exam, the Veteran had decreased hearing in his right ear, more than left ear. However, April 2009, September 2009, September 2011, January 2012, and June 2012 private treatment records show grossly normal hearing on physical exam. Service connection for the Veteran's hearing loss disability must be denied as the preponderance of the evidence is against the claim. As for the right ear, the Court recently indicated that a notation of 40 decibels or above at one of the frequencies constitutes a "notation" of a hearing defect on examination at entry into service even without a health care professional's interpretation of the audiometric readings. McKinney v. McDonald, 28 Vet. App. 15 (2016). Thus, a defect in right ear hearing was noted on the preinduction examination in this case. Therefore, the presumption of soundness does not apply to the right ear because a defect was noted on the preinduction examination, and the only issue is whether the right ear hearing loss disability was aggravated by service. See Horn, 25 Vet. App. at 234 ("There is a related but distinctly different statutory provision that pertains to cases in which a preexisting condition is noted on an entrance examination and the claimant contends that this condition was aggravated in service. This provision is known as the "presumption of aggravation"). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable (obvious or manifest) evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). These provisions apply to only one situation: where the induction examination notes a preexisting condition that is alleged to have been aggravated. Horn, 25 Vet. App. at 238 (quoting Wagner, 370 F.3d at 1096 ("[I]f a preexisting disorder is noted upon entry into service ... the veteran may bring a claim for service-connected aggravation of that disorder. In that case section 1153 applies and the burden falls on the veteran to establish aggravation." (emphasis added)). The right ear hearing remained the same at entrance and separation. See March 1966 Pre-Induction Examination and August 1968 Separation Examination. Thus, the right ear hearing loss did not increase in severity during service. Consequently, the presumption of aggravation is not for application. Moreover, as there was no increase in severity, there was no aggravation of the preexisting right ear hearing loss. As for the left ear, audiometric scores on the preinduction examination were between 0 and 20 at all decibels, and therefore considered normal. Hensley, 5 Vet. App. at 160. Thus, as for the left ear, the Veteran is presumed sound at entry into service. 38 U.S.C.A. § 1111. In addition, post-service records reveal no treatment or diagnosis for a hearing loss condition until after discharge during a February 2009 private treatment visit, approximately 41 years after service. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, is one factor, along with those above including the negative nexus opinion, that can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent that the Veteran claims he had hearing loss in and since service, the Board notes that the Veteran indicated on the separation report of medical history that he did not have ear trouble, and the physician's summary and elaboration of all pertinent data reflected other problems but did not reference hearing loss. Given that notation of hearing loss would be expected to be listed among the summary of data along with the Veteran's other complaints, the Board finds that this is evidence of a lack of hearing loss in service. See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) ("[T]he Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation."); Horn v. Shinseki, 25 Vet.App. 231, 239 n.7 (2012) (recognizing that the absence of evidence cannot be substantive negative evidence without "a proper foundation . . .to demonstrate that such silence has a tendency to prove or disprove a relevant fact"); Buczynski v. Shinseki, 24 Vet.App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded"). The Board finds that the contemporaneous statements indicating a lack of hearing loss are of greater probative weight than statements made many years later during the course of an appeal from the denial of compensation benefits. In addition, the evidence does not reflects that sensorineural hearing loss manifested to a compensable degree within the one year presumptive period after service. As such, the chronic disease presumption is not applicable. As to the lay evidence, the Board has considered the lay statements of the Veteran and other laypersons on this question, indicating that the Veteran's hearing loss is caused by or aggravated by service. The Veteran is competent to state that he experiences hearing loss. Lay evidence is competent as to some matters concerning the nature and cause of disability. Jandreau v. Shinseki, 492 F.3d 1372, 1377 (Fed. Cir. 2007). To the extent that the Veteran and other laypersons claim that the Veteran's hearing loss is related to in-service noise exposure, the statements as to the etiology of hearing loss, as opposed to its existence, are testimony as to an 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. Jandreau, 492 F.3d at 1377, n. 4 ("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"). In any event, to the extent that the Veteran's statements are competent, the specific, reasoned opinion of the trained health care professional who conducted the July 2009 VA examination is of greater probative weight than the more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for bilateral hearing loss disability. The benefit of the doubt doctrine is therefore not for application with regard to this claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for bilateral hearing loss disability is denied. REMAND With respect to the remaining claims on appeal, the Board has reviewed the claims file, and determined that additional development is warranted. Right Eye Disability A right eye defect was noted at entry into service, as the March 1966 pre-induction examination indicates that there was a blind spot on the Veteran's right eye. On examination, vision in the right eye was 20/30. Service treatment records show changes in right eye vision. In October 1966 right eye vision was 20/40, unaided, and the Veteran was placed on duty with limitations due to his right eye condition. In an October 1966 letter, the Veteran's optometrist indicated that the Veteran's right eye vision was approximately 20/50 and not correctible to a normal vision, indicating some degree of macular impairment. In January 1967 right eye vision was 20/40 and in February 1967 it was 20/30. At his August 1968 separation from service examination, right eye vision was 20/30. When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Thus, the dispositive issue in this regard is whether the Veteran's preexisting defect, infirmity, or disorder relating to his right eye was aggravated by his service. In determining whether there has been aggravation, the statute and regulation indicate that the first question to be asked is whether there was an increase in disability. See 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306 (a preexisting injury or disease will be considered to have been aggravated by service "where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease"). In other words, if there is an increase in disability during service, aggravation is presumed, and this presumption can only be rebutted with clear and unmistakable evidence that the increase was due to the natural progress of the disease. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993). If VA determines that there has been an increase in disability, the presumption of aggravation applies regardless of whether the degree of worsening is enough to warrant compensation under the VA rating schedule. Browder v. Derwinski, 1 Vet. App 204, 207 (1991). The Veteran was afforded a VA examination in December 2009 to determine the nature and etiology of a right eye disability. The examiner noted a history of a spot in the back of the right eye since the age of 12 from an unknown cause. The examiner diagnosed microscopic macular scar right eye present since age of 12 that was probably due to a minor traumatic injury. The examiner opined that the Veteran's right eye disability was not aggravated by service. As rationale, the examiner stated that there is no evidence of aggravation in service treatment records. No further explanation was provided. The Board finds this opinion inadequate as it did not consider service treatment records showing right eye vision changes. Given the centrality of the issue of aggravation to this case, the Board finds that the medical opinion should specifically address right eye vision changes and other symptoms during service. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Nicholson, 21 Vet. App. at 312. Thus, an addendum opinion to the December 2009 VA examination is necessary to consider relevant service treatment records and to determine any causal relationship to service. Back Disability The Veteran claims that he developed a back disability due to service, or secondary to his knees or foot disabilities. A January 2014 Board order remanded the issue for a VA examination to determine the nature and etiology of a back disability. A September 2009 VA medical opinion reflects that after reviewing the claims file, service treatment records, and the July 2009 VA joint examination report, the examiner assessed that the Veteran's back disability was not related to his service connected knee disabilities. The Veteran was not examined, and the examiner did not provide opinions as to whether the Veteran's service connected knee and/or foot disabilities aggravated his back disability, and direct service connection. Pursuant to a January 2014 Board remand, the Veteran was afforded a VA examination in February 2014. The Veteran reported that gradual lumbar pain started in 1971 or 1972 following discharge from service. Based on a review of the claims file and in-person examination, the examiner diagnosed lumbosacral strain and degenerative arthritis of the spine. The examiner opined that it is less likely as not that a current lumbar back disability was caused by or aggravated by active service. As rationale, the examiner stated that there was no evidence of a lumbar condition prior to service or treatment during service, including at separation. The examiner noted that lumbar degenerative disc disease is caused by a lifetime of wear and tear on the lumbar disc area. As for secondary service connection, the examiner opined that it is less likely as not that a current lumbar condition was caused by or aggravated by service-connected bilateral chondromalacia patellae (knee) disability. As rationale, the examiner stated that medical literature does not support that bilateral chondromalacia patellae causes or aggravates a lumbar strain or degenerative disc disease. The Veteran was afforded another VA examination in May 2016. The Veteran claimed that his back condition was related to his knee and foot disabilities. Based on a review of the claims file and in-person examination, the examiner diagnosed degenerative arthritis of the spine. The examiner opined that it is less likely as not that the current lumbar disability is secondary to service connected bilateral knee disability or the result of limitation of flexion in the right knee. As rationale, the examiner stated that the Veteran's medical history raises proximity issues and that, based on the current clinical evaluation, the pathology of degenerative spine is not present in the right knee. Although the Veteran was afforded multiple VA examinations, the examiners did not provide opinions on the relationship between the Veteran's current back disability and any identified foot disabilities. The January 2014 Board remand instructed the RO to provide the Veteran with a VA examination and obtain opinions as to the etiology of the Veteran's back disability. Specifically, the Board directed the RO to obtain an etiology opinion that include whether a current back disability is related to, or increased in severity beyond its natural progression, due to the Veteran's service-connected right and left knee disabilities, or any identified foot disabilities. The February 2014 and May 2016 VA examiners provided opinions on general service connection and secondary service connection to the Veteran's bilateral knee disabilities. However, they did not provide opinions on secondary service connection to any identified foot disabilities. To this regard, the Board notes that the RO granted service connection for bilateral pes planus (foot) in July 2014, after the February 2014 VA examination and prior to the May 2016 VA examination. Thus, based on lack of compliance with prior remand directives, a remand is necessary to obtain an addendum opinion to the most recent May 2016 VA examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Ongoing VA medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the claims for service connection for a right eye disorder and back disorder are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records, to include records from North Texas Health Care System which have not already been associated with the claims file. 2. After completing the above development, return the claims file to the December 2009 VA examiner (or other qualified examiner, if unavailable) that conducted the eye examination for preparation of an addendum opinion. The entire claims file, including a copy of this remand, must be made available to the examiner, and the examiner should confirm that such records were reviewed. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a complete review of the record and clinical evaluation, the examiner is asked to provide the following medical opinions: Was the Veteran's preexisting right eye blind spot, which was noted on the preinduction examination, aggravated by service? If there is a current right eye disability unrelated to the preexisting right eye blind spot noted on the preinduction exam into service, it is at least as likely as not that such disability is related to service. The examiner must specifically comment on the right eye abnormalities noted in service, to include worsening vision, being placed on duty limitations due to the right eye, and the notation of some degree of macular impairment. The examiner should consider service treatment records, to include March 1966, October 1966, January 1967, February 1967, and August 1968 records showing right eye visual acuity measurements. The examiner must provide a complete rationale in support of any opinions proffered. If the examiner is unable to provide any requested opinion, the examiner must explain why such an opinion would be speculative. 3. Then, return the claims file to the May 2016 VA examiner (or other qualified examiner, if unavailable) that conducted the back examination for preparation of an addendum opinion. The entire claims file, including a copy of this remand, must be made available to the examiner, and the examiner should confirm that such records were reviewed. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a complete review of the record and clinical evaluation, the examiner should provide the following medical opinions: (a) Is it is at least as likely as not (a 50 percent probability or greater) that a back disability is either (a) caused or (b) aggravated by his service-connected right and left knee disabilities and/or foot disabilities. If so, describe the baseline level of disability prior to aggravation. (b) If the answer to that question is negative, the examiner should opine as to whether it is at least as likely as not (a 50 percent probability or greater) that a back disability began during active service, is due to an event or injury during service, or is otherwise etiologically related to service. 4. After the additional evidence is received, readjudicate the claims remaining on appeal. If any benefit sought is not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs