Citation Nr: 1751069 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 09-37 282 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a left eye disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD P. Poindexter, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1989 to February 2009. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise Idaho. Jurisdiction of the appeal currently resides with the Atlanta, Georgia RO. In March 2014 and March 2016, the Board remanded the case for further development. In June 2017, the Board requested a medical expert opinion from the Veterans Health Administration (VHA) pursuant to 38 C.F.R. § 20.901 (2016), which was received in July 2017. FINDING OF FACT The Veteran's left eye disabilities were not incurred in and are not otherwise related to his active military service. CONCLUSION OF LAW The criteria for service connection for an eye disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) VA's duty to notify was satisfied by a letter in October 2008. See 38 U.S. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017); See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's service treatment records (STRs) are associated with his record, and VA has obtained pertinent records he has identified. He was afforded examinations by or on behalf of VA in November 2008 and April 2014 (with an addendum opinion in July 2016), and as noted above, a July 2017 VHA opinion was secured. The Board finds the April 2014 VA examination, July 2016 addendum opinion and VHA opinion (cumulatively) adequate for adjudication of the claim; the reports note all necessary findings, and the examiner and consulting expert expressed familiarity with the record/the Veteran's medical history and included rationale with the opinions offered. 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 this matter, 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 Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Factual Background The Board notes that it has reviewed all of the evidence in the 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 deemed appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran's service treatment records (STRs) show he was treated form complaints of left eye soreness, feeling of swelling, fading vision and tunnel vision. Upon examination, no corneal abrasion was found and a history of migraine was noted. a July 2006 diagnosis of left eye conjunctivitis (pinkeye). An October 2006 STR notes the Veteran's complaint of irritation to the left eyelid. Upon examination, he was diagnosed with blepharitis of the left eye. A June 2008 STRs notes his complaint of periorbital left eye pain increasing with light exposure. The etiology was noted to be "uncertain". On November 2008 VA eye examination, the Veteran reported eye pain, swelling, discharge, watering and throbbing. The examiner stated that he was unable to make a diagnosis without resorting to mere speculation. He provided no reason as to why he could not render an opinion but recommended the Veteran undergo an evaluation with an ophthalmologist with "CT or MRI Imaging of maxillary and orbital areas". Post service private treatment records from August 2009 to March 2014 note the Veteran's complaints, diagnoses and treatment related to left eye pain. For example, in an April 2011, the Veteran reported blurred vision, frequent headaches and left eye soreness. The diagnosis was ocular hypertension. In May 2011 the Veteran underwent a CT scan of his head; sinus, orbits and calvarium were interpreted as unremarkable. In August 2011 he reported headaches, sensitivity to light and left eye pain. Ocular hypertension and trigeminal neuralgia was diagnosed. At an April 2014 Disability Benefit Questionnaire (DBQ), the Veteran reported headaches and pressure around his eyes. He reported that he wears dark sunglasses due to sensitivity to the sun. The diagnoses were glaucoma, cataracts, and maculopathy, of both eyes. The examiner noted that the Veteran's STRs show treatment for pinkeye and opined that his diagnosed eye conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She stated, "[c]ataracts are a change within crystalline lens and not related to the conjunctiva of the eye. Glaucoma is a condition that indicates the eye is not filtering aqueous and is not related to pink eye of the conjunctiva. Macular Degeneration is a condition that results from changes in the retinal layer and is not related to the conjunctiva or pink eye." The examiner opined that the Veteran's eye conditions do not impact his ability to work. Pursuant to the Board's March 2016 remand, an addendum opinion was provided in July 2016. The examiner opined that the Veteran's cataracts, macular degeneration and glaucoma of the left eye are less likely than not related to complaints of periorbital eye pain in service. She noted that cataracts OU are natural aging of the crystalline lens which become cloudy with age, macular degeneration OU is a "natural aging change of the macula that have dry drusen form within the macula," and glaucoma OU is related to the "aqueous humor flow within the eye and not related to the periorbital structures". The examiner further opined that it is less likely than not that the Veteran's complaint of left periorbital eye pain during service were early manifestations of the diagnosed eye conditions. She noted that cataracts and macular degenerations are conditions that do not produce pain and early manifestations of glaucoma would not cause periorbital eye pain since the condition is "within the eye and not of the periorbital structure". A VHA specialist opinion was requested in June 2017. In the opinion received in July 2017, the ophthalmologist opined that it is unlikely that the Veteran's April 2011 diagnosis of ocular hypertension caused periorbital left eye pain during service in June 2008 since ocular hypertension does not cause eye pain and does not cause any visual symptoms. He noted that "ocular hypertension is a diagnosis made at slit lamp by measuring intraocular pressure and it not a condition that causes symptoms. He indicated that the Veteran's intraocular pressure was measured during a June 2008 evaluation, in service and it was normal. The examiner further opined that it is unlikely that ocular hypertension is a result of the Veteran's service-connected hypertension or diabetes mellitus since ocular hypertension is an "idiopathic condition with no established risk factors". Analysis The Veteran is seeking entitlement to service connection for a left eye disability. It is not in dispute that the Veteran now has a left eye disability, as private treatment records and the April 2014 VA examination notes various diagnoses related to the eyes. It is also not in dispute that the Veteran reported periorbital left eye pain during service on various occasions. What remains necessary to substantiate the claim of service connection is evidence that such disabilities are etiologically related to his in-service complaints noted therein. While the Veteran's STRs note a complaint of left periorbital left eye pain and a diagnoses of left eye conjunctivitis and blepharitis, there is no competent evidence of a nexus between the currently diagnosed left eye disabilities and the in-service complaints and diagnoses. The Board notes that whether there is a nexus between the Veteran's eye disabilities and his service to include conjunctivitis and reports of periorbital eye pain therein, is a medical question beyond the scope of common knowledge or capability of resolution by lay observation. It requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The only competent (medical) evidence in the record that directly addresses the matter of a nexus between the Veteran's current eye disabilities and his service is found in the April 2014 and July 2016 VA opinions and the March 2017 VHA advisory medical opinion, which are against the Veteran's claim. Specifically, the April 2014 examiner opined that the Veteran's eye disabilities were less likely than not related to his service; she explained that cataracts, glaucoma and macular degeneration are not related to the conjunctiva of the eye. In the July 2016 addendum opinion, the examiner opined that it was less likely than not that complaints of periorbital eye pain in service were early manifestations of the Veteran's diagnosed cataracts, macular degeneration and glaucoma of the left eye because cataracts and macular degenerations are conditions that do not produce pain, and early manifestations of glaucoma would not cause periorbital eye pain since the condition is "within the eye and not of the periorbital structure." The March 2017 VHA examiner explained that ocular hypertension does not cause eye pain and does not cause any visual symptoms, therefore it is not likely that the Veteran's diagnosis of ocular hypertension caused periorbital left eye pain during service in June 2008. He further noted that the Veteran's intraocular pressure was normal in June 2008. Lastly, the VHA examiner opined that it is unlikely that ocular hypertension is a result of the Veteran's service-connected hypertension or diabetes mellitus since ocular hypertension is an "idiopathic condition with no established risk factors." The Board finds the opinions, cumulatively merits substantial probative weight. The opinions when read together, reflect familiarity with the record, the Veteran's medical history and include adequate rationale. The opinions are probative evidence in the matter, and in the absence of probative evidence to the contrary are persuasive. While the Veterans is competent to report symptoms, such as eye pain, blurred vision and sensitivity to light, the etiology of an eye disability fall outside the realm of common knowledge of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Therefore, his own opinion is not probative evidence in the matter of a nexus between his current eye disabilities and his service. In light of the foregoing, the Board finds that the preponderance of the evidence is against this claim. Accordingly, the appeal in the matter must be denied. ORDER Entitlement to service connection for a left eye disability, to include ocular hypertension, glaucoma, cataracts and macular degeneration, is denied. ____________________________________________ E.I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs