Citation Nr: 1756547 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 11-06 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an increased initial disability rating for posttraumatic stress disorder (PTSD), currently rated as 30 percent disabling prior to December 8, 2010 and 50 percent disabling since December 8, 2010. 2. Entitlement to service connection for blindness, claimed as secondary to PTSD. 3. Entitlement to compensation for blindness under 38 U.S.C.A. § 1151 (West 2014). 4. Entitlement to special monthly compensation at the rated provided by 38 U.S.C.A. § 1114(n) (West 2014). 5. Entitlement to special monthly compensation at the rate provided by 38 U.S.C.A. § 1114(o) (West 2014). 6. Entitlement to service connection for a seizure disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Nye, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1967 to April 1968. This case comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans' Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In April 2010, the RO granted the Veteran's claim for service-connected compensation for PTSD and assigned an initial disability rating of 30 percent. The RO denied the Veteran's claim for compensation for blindness on two different theories, concluding that the Veteran's blindness was unrelated to his active duty service and also that blindness was not caused by the alleged carelessness or negligence of VA medical personal, which meant he was not eligible for compensation under 38 U.S.C.A. § 1151. The Veteran appealed these rulings to the Board. In December 2010, the RO increased the disability rating for PTSD from 30 percent to 50 percent. The request for a higher rating remains on appeal because the Veteran has not expressed satisfaction with the amount of the increase. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). In subsequent rating decisions, issued in February 2011 and November 2012, respectively, the RO denied the Veteran's claims for special monthly compensation based on the need for the aid or attendance of another and denied service connection for a seizure disorder. In March 2013, the Veteran participated in a videoconference hearing before a Veterans Law Judge (VLJ) who is no longer employed by the Board. Because of the first VLJ's departure, the Veteran had the right to a second hearing before the VLJ who would decide his appeal. For that reason, a second videoconference hearing, before the undersigned, took place in November 2016. Transcripts of both hearings have been associated with the Veteran's electronic claims file. This case was remanded for further development in April 2014 and July 2016. To help decide the issues concerning compensation for blindness, the Board requested an expert medical opinion in September 2017. The issues of entitlement to service connection for a seizure disorder and for special monthly compensation at the rate provided by 38 U.S.C.A. § 1114(o) are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether idiopathic pars planitis, which eventually led to the Veteran's blindness, had its initial onset during active duty service. 2. Throughout the appeal period, the evidence is at least evenly balanced as to whether PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. 3. As a result of the Board's other rulings in this decision, the Veteran will be granted service connection for blindness, effective August 31, 2009. 4. The Veteran did not raise the issue of entitlement to compensation for blindness pursuant to 38 U.S.C.A. § 1151 until January 2010. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in the Veteran's favor, his current blindness is the result of a disease (pars planitis) which had its initial onset during active duty service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2017). 2. Prior to December 8, 2010, the criteria for a disability rating of 50 percent for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Codes 9310, 9411 (2017). 3. Since December 8, 2010, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Codes 9310, 9411. 4. Given the Board's decision to grant service connection for blindness, effective August 31, 2009, the Veteran's claim for compensation for blindness under 38 U.S.C.A. § 1151 is moot. Aronson v. Brown, 7 Vet.App. 153, 155 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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 and 3.326(a) (2017). Since the issues of service connection for blindness and special monthly compensation are being resolved in the Veteran's favor, the Board does not need to consider whether VA complied with the VCAA with respect to those claims. See Wensch v. Principi, 15 Vet. App. 362, 367-368 (2001). For the issue of an increased initial rating for PTSD, the Board finds that VA has complied with its duties under the VCAA. Duty to Notify The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The notice VCAA requires depends on the general type of claim the Veteran has made. "As a result, generic notice provided in response to a request for service connection must differ from that provided in response to a request for an increased rating." Vasquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). This appeal arises from the Veteran's disagreement with the disability rating assigned after VA granted service connection for PTSD. Because the claim for service connection was granted, the claim is substantiated, additional notice is not required, and any prior defect in the notice is not prejudicial. See Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003. VA's General Counsel has determined that while VA is required to issue a statement of the case when a "downstream element" - such as disagreement with the initial assigned disability rating - arises after the initial adjudication of a claim, 38 U.S.C.A. § 5103(a) does not require the mailing of a separate notice concerning the information and evidence necessary to substantiate the newly raised issue. Id. Duty to Assist VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claim. Service treatment records, post-service medical treatment records, and lay statements have been associated with the record. The AOJ arranged for examinations of the Veteran's PTSD in February 2010, December 2010, June 2011 and November 2014. As the Board will explain in its analysis below, these examination reports were based on personal interviews with the Veteran and a review of the relevant medical records. The June 2011 VA examiner made a finding concerning the Veteran's insomnia which is inconsistent with the other examination reports and with some post-service treatment records. Because the Board has resolved the issue raised by the examiner in the Veteran's favor, this weakness in the examiner's report does not require a remand for further assistance. Having taken these steps, the Board finds that VA has complied with its duties to notify and assist the Veteran in this case. II. Service Connection for Blindness General Service Connection Principles Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2014). "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'- the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Factual Background The Veteran in this case is completely blind in both eyes. In April 1975, he had a surgical enucleation of his left eye, followed by the placement of a prosthetic eye. A similar operation on his right eye took place in April 1981. In his written statements and through medical evidence submitted in support of his claim, the Veteran seeks disability compensation for blindness based on many different theories. The Veteran served on active duty in the United States Navy from November 1967 to April 1968. He was discharged from the Navy in April 1968. He claims he was raped by another sailor and, as a result of this incident, he was later granted service-connected compensation for post-traumatic stress disorder (PTSD). Service treatment records show that the Veteran was admitted to a naval hospital after he "blacked out" three times and, on one of these occasions, hit his forehead. The admitting diagnosis was convulsive disorder. According to the hospital summary, the Veteran said he had been "shaking" but "there was no tongue biting, urinary incontinence, foaming at the mouth or crying out . . . . Each spell was preceded by a feeling of depression, a lump in the chest and rapid breathing." Unable to attribute these episodes to a specific cause, the Veteran was examined by a psychiatrist, who diagnosed immature personality. At the psychiatrist's recommendation, the Veteran was discharged as being unsuitable for further service. The psychiatrist wrote, "I seriously doubt this man will ever be able to complete his enlistment in the Navy. He is too immature and dependent to [sic] his family and my opinion is that his 'seizures' are an emotional basis." According to his post-service VA treatment records, the Veteran developed iritis and pars planitis, which at first was most severe in his left eye. He had a left eye cataract extraction surgery in July 1973 and an intracapsular right eye cataract extraction in December 1973. Progress notes from a visit to the VA Medical Center in Omaha Nebraska in late August 1973 indicate a potential link between the Veteran's poor oral hygiene and iritis. But according to other progress notes, "Evaluation by Oral surgery revealed no significant dental infection which could be contributing to pars planitis." In January 1974, the Veteran was treated in a non-VA hospital for pain in his left eye. The impression was pars planitis, recurrent with vitreous hemorrhage and neovascular glaucoma secondary to rubeosis iridis of the left eye. The medical staff there suggested cyclocryotherapy. Subsequent VA progress notes indicate treatment with various drugs, including prednisone. But it is clear from the subsequent left eye enucleation that the treatment did not succeed. There was a similar series of unsuccessful treatments, including cyclocryotherapy, prior to the right eye enucleation in April 1981. The final diagnosis was post right eye enucleation secondary to end stage pars planitis with no light perception and untreatable, painful right eye. In support of his claim, the Veteran has submitted letters from three medical professionals. One letter is from a neurologist, Dr. R.A., and is dated August 2010. The letter indicates that Dr. R.A. saw the Veteran for an evaluation of insomnia, anxiety, depression and "limitations in the setting of blindness and decreased hearing." The letter refers to a review of records "from the VA, documenting his enucleation for iritis, glaucoma, etc." Dr. R.A.'s opinion is based on the assumption that the Veteran had a fall at the base while using the bathroom and, after being attended and evaluated by medics, "went on to fall down some stairs apparently while the medics were there, having a significant head injury. He went on to have a two-month hospitalization after that and was felt to have a psychiatric illness." The next paragraph refers to "other problems, including visual blurring. He states he had reddened eyes with blood in his eyes at the time of his fall." According to Dr. R.A., "This gentleman clearly had significant head injury with his fall when he was age 20 in the service. He had a two-month hospitalization after that fall, which would have had some significant relation to his head injury. Frontal lobe syndrome, postconcussion syndrome, subsequent personality change, and the development of features of bipolar illness are suggested in this circumstance. At least some of this gentleman's visual complaints of iritis, glaucoma, visual distortion, etc. are related to his fall. . . . Clearly, he had a significant head injury and significant postconcussion treatment with a two-month hospitalization after that fall." The Veteran also submitted a letter dated August 2010 from Dr. P.D., a physician specializing in eye treatment. According to Dr. P.D., pars planitis or peripheral uveitis "is a type of inflammation of the uveal tract that can occur in one or both eyes. Back in the early 1980s, our ability to diagnose the underlying etiology was somewhat limited. Even with current immunologic and diagnostic testing, finding the etiology for pars planitis is still difficult. Pars planitis or peripheral uveitis is a descriptive term for where the inflammation is located generally affecting the peripheral uvea and ciliary body. The inflammation can extend into the anterior part of the eye causing an inflammation of the iris called iritis. The inflammation can also extend posteriorly with resultant edema or swelling in the retina." Dr. P.D. explained that "iritis" is "a descriptive term for the location of the uveitis. It typically can be associated with blurred vision, redness and sensitivity to light. In the milder or earlier forms one can still have a visual acuity of 20/20. As it becomes more protracted or severe the vision starts to decrease. Untreated severe uveitis or pars planitis can result in glaucoma, cataracts, significant retinal pathology, scarring, pain and ultimately blindness, which was the case for [the Veteran]." The Veteran also submitted a letter from Dr. D.R., a physician in family practice. Dr. D.R.'s letter, dated September 2010, indicates that the Veteran has "a long-standing history of PTSD. As a result of this, he has significant sleep disturbances. Because of such, he has developed and [sic] iritis. He needs a referral to an ophthalmologist for further evaluation of this iritis. Again, at this time, BP of allergy of the iritis is being attributed to the sleep disorders secondary to the posttraumatic stress disorder." To help decide the Veteran's claim, the Veteran was examined by a VA physician in February 2010. The diagnosis was status post enucleation of blind, painful eyes from chronic uveitis with past history of iritis, uveitis and pars planitis. The examiner acknowledged the Veteran's statement alleging a potential relationship between iritis and his PTSD and that "the sclera depressed exams performed at the VA eye clinic many years ago led to worsening of his condition." In the examiner's opinion, it was less likely than not that chronic iritis was caused by PTSD or a claimed sleep disorder. In his explanation for this conclusion, the examiner quoted a long list of conditions which are causes of uveitis (noting that uveitis can mean iritis, anterior uveitis, posterior uveitis, panuveitis, and pars planitis). The list did not include PTSD or sleep disorders. In his opinion, "PTSD, depression, sleep disorders, and other psychiatric disorders do not cause uveitis." As for the claim that examinations at the VA hospital caused the Veteran's condition to worsen, the examiner wrote that "The scleral depressed exams that he describes were likely performed to search for swelling of pars plana (pars planitis) and/or retinal tears or detachments from chronic inflammation; it is my opinion that these likely did not lead to progression of his disease." The examiner did not provide an explanation for this conclusion. The examiner's report also indicates that he failed to review service treatment records. Due to the shortcomings of the February 2010 report, VA arranged a new examination with a VA physician in July 2011. According to the examiner, iritis, uveitis, and pars planitis were not the result of head trauma in service. The examiner explained that the Veteran lost both eyes "to inflammation that led to blind painful eyes, and then to the eventual enucleation of both eyes." Reviewing the service treatment records, the examiner noted that the Veteran reported having "blacked out" after a convulsive episode but regained consciousness a few minutes later "and that someone witnessed him shaking. He had none of the normal sequelae associate [sic] with a seizure though." He told the admitting physician he hit his forehead but the records did not indicate bruising, swelling, blood or other signs of significant head trauma. A neurological examination was within normal limits. X-rays indicated a normal skull and an EEG was also normal. The Veteran was hospitalized over one month after the head injury. But there were no "eye findings or complaints . . . included in the discharge summary." The psychiatric team indicated the Veteran's seizures were "on an emotional basis." The diagnosis was immature personality. The Veteran's eyes were apparently normal at the time of his April 1968 separation examination. Visual acuity was 20/20 in both eyes "and he passed a Farnsworth color vision test. There is no mention that [the Veteran] was having any eye problems at this visit which occurred more than 2 months after he reported hitting his forehead during an emotional 'seizure.'" According to the examiner, inflammation of the eye resulting from head trauma usually occurs "when the eye itself is hit or penetrated." But there was no evidence of any trauma to the Veteran's eye in service and likewise "no evidence that the trauma to the head was significant enough to cause significant indirect trauma to the eyes. Even if [the Veteran] had had blunt trauma to the eye, the onset of inflammation usually occurs within 3 days of trauma according to the Wills Eye Manual. Eye inflammation after trauma usually presents with pain, photophobia, and tearing. None of these symptoms were reported to have happened during the patient's hospital stay which lasted over a month. He was being evaluated by the neurology team during his hospitalization for a head injury. They would most likely have been examining his eyes or at least shining light into his pupils which would most likely have elicited photophobia if inflammation was present. Given all of the above, [the Veteran's] eventually blinding pars planitis/iritis/uveitis (all terms used interchangeably in his record) was not caused by head trauma sustained during military service. " The examiner was asked to respond to eye records going back to August 1973 indicating "a long battle with inflammation of both eyes that led to blind painful eyes and then to enucleation of both eyes." He wrote that the Veteran "received aggressive treatment in an effort to save his vision, but these efforts did not succeed. However, these records do not show any connection between [the Veteran's] unfortunate condition and his head injury in service." The examiner addressed the August 2010 letter from the neurologist Dr. R.A. According to the examiner, Dr. R.A.'s conclusion that "At least some of [the Veteran's] visual complains [sic] of iritis, glaucoma, visual distortion, etc are related to this [in-service fall]" was inconsistent with service treatment records indicating that the Veteran's head injury was not significant and that the Veteran left the hospital with a psychiatric diagnosis. The examiner wrote that "It appears that [Dr. R.A.] made his statement based on what he was told by [the Veteran] about the hospitalization many years after the hospitalization occurred and not the record of the hospitalization itself." The examiner acknowledged a letter from the Veteran's friend, J.H., who indicated that, when the Veteran was discharged from the Navy, he seemed agitated and had "blood shot eyes", "blinked often," and "stated it was hard for him to focus his eyes." The examiner indicated that "while eyes with iritis are often red, there are many causes of red eyes that are not iritis. [The Veteran's] eyes could have also been dry from the air in the bus. This information [J.H.'s letter] does not establish causality between [the Veteran's] reported head injury and his eventual eye inflammation." The examiner failed to address a similar letter from the Veteran's brother. While the July 2011 VA examiner thoroughly discussed Dr. R.A.'s theory that an in-service head injury caused the Veteran's eye problems, the examiner failed to address several of the Veteran's contentions. The examiner also relied on the Veteran's 20/20 vision at the time of the separation examination to support his conclusion that the Veteran's iritis did not have its onset in service. This reasoning is undermined by the letter of Dr. P.D., which indicates that a person can have 20/20 vision during the early stages of iritis. In May 2012, VA obtained an addendum opinion from the July 2011 VA examiner. The report answered each of the following questions in the negative: 1) was bilateral blindness caused by carelessness, negligence, etc. [?] 2) was bilateral blindness at least as likely as not incurred in or caused by [the Veteran] hitting his [head] after passing out that occurred on active duty in 2/68? 3) Is the veteran's bilateral blindness caused by or a result of sleeplessness (leading to red eyes) caused by PTSD? Once again, the examiner concluded that blindness was not caused by negligence without addressing the Veteran's specific theories of negligence. The examiner gave a second, detailed explanation for his disagreement with Dr. R.A.'s theory that blindness was caused by an in-service head injury. According to the examiner, the Veteran's blindness "was caused by his severe bilateral uveitis and the sequelae of uveitis and its treatment. It was not caused by his sleeplessness caused by his PTSD. There [are] many known causes of uveitis and extensive lists can be found in many ophthalmology texts. Sleeplessness and PTSD are not among the causes of uveitis identified. Therefore, it is less likely than not that [the Veteran's] sleeplessness from his PTSD caused his bilateral blindness." VA obtained another opinion concerning the blindness claim from a VA staff physician in October 2014. The examiner wrote that there was "no incident or illness documented in the [service treatment] records that would have plausibly caused uveitis in this case. There are a number of medical conditions other than eye conditions that can plausibly cause uveitis. None are present in this case. In regards to the lay statements indicating that [the Veteran] had red eyes shortly following service this does not in any way indicate that uveitis was present. . . . If uveitis had been the cause of the red eye it is highly unlikely that it would have resolved on its own without the patient seeking treatment, which didn't happen at that time. The uveitis was then diagnosed years later." It is not clear why the examiner concluded that the red, bloodshot eyes described by the Veteran, his brother and his friend shortly after service "resolved on [their] own without the patient seeking treatment . . . ." Indeed, in a September 2010 letter, the Veteran stated that he continued to have red eyes during and after service and that the reason he did not seek treatment for approximately two and one half years was that he continued to have 20/20 vision, corrected with glasses. Again, the letter of Dr. P.D. indicates that 20/20 vision can coexist with iritis during the early stages of the condition. In July 2017, the Board requested a review of the evidence and a new opinion from an expert ophthalmologist associated with the Veterans Health Administration (VHA), because the previous opinions concerning service connection for blindness either failed to adequately explain the reasons for the respective examiners' conclusions or failed to address all of the contentions raised by the Veteran which, if true, could potentially make him eligible for disability compensation for his blindness. The VHA expert provided his opinion in a letter dated September 2017. The letter begins with a summary of the medical evidence, which is substantially similar to the summary the Board has given above. The expert noted that the service treatment records did not include a full, detailed eye examination. The letter further explained that pars planitis is a type of uveitis. According to the expert, complications from idiopathic pars planitis caused cystoid macular edema, retinal venous occlusions and intraocular hemorrhage, which eventually required the removal of both eyes. In his September 2017 letter, the VHA expert explained that he reviewed medical literature - specifically the Basic Clinical Science Course of the American Academy of Ophthalmology Retina and Vitreous for 2013-2014. The literature describes the Veteran's pars planitis as a specific form of idiopathic uveitis "that typically affects young adults and children, with peaks occurring in the age ranges of 5-15 years and 25-35 years." The 2015-2016 version of the same course materials indicated that 80 percent of intermediate uveitis cases are idiopathic. According to the expert vitreous cells or segmental phlebitis can be observed in the absence of decreased vision. In the expert's opinion, there is at least a 50 percent probability that the Veteran developed uveitis during his active duty service. To support his opinion, the expert noted that, during his time in the Navy, the Veteran was within the typical age range for onset of pars planitis and reported visual complaints - specifically, bloodshot eyes - which could have been related to pars planitis. Given the absence of a detailed in-service eye examination report, "the patient may have had pars planitis while in the service but not yet had vision loss associated with the condition. There is no scientific basis to support a claim that an in-service head injury caused pars planitis, and this claim is not consistent with the epidemiology of the disease. 80% of intermediate uveitis cases are idiopathic as is the case in this patient." The VHA expert's September 2017 letter opinion went on to reject the theories that pars planitis was related to sleep deprivation associated with service-connected PTSD or that the Veteran went blind as a result of carelessness, negligence, lack of proper skill, or error in judgment on the part of VA medical personnel. Analysis The Veteran's current blindness has been established by medical evidence. Although the service treatment records do not mention red or bloodshot eyes, the Veteran is competent to testify that he experienced red or bloodshot eyes during active duty. In addition to his own testimony, the Veteran has submitted written statements from his brother and from a friend. Both of these statements indicate that, when the respective authors met the Veteran shortly after he left the Navy in the spring of 1968, he had red or bloodshot eyes. Because red or bloodshot eyes are susceptible to observation by a layperson, the Board accepts these statements as true. Thus, the evidence satisfies both the current disability and the in-service disease, injury or event requirements of the claim for service connection for blindness. Accordingly, the success of the claim depends on the existence of a causal connection between the Veteran's current blindness and the in-service complaints concerning his eyes. See Holton, 557 F.3d at 1366. On the issue of whether the required connection exists, the Board finds that the most persuasive evidence is the letter opinion of the September 2017 VHA ophthalmologist. As the Board has explained, each of the previous VA medical opinions had serious weaknesses in the reasoning provided for the examiners' conclusions. The September 2017 VHA expert had access to the Veteran's medical records, both during and after service. He also had subject matter expertise concerning diseases of the eye and the opportunity to review each of the prior medical opinions, both favorable and unfavorable. Most importantly, the September 2017 VHA expert gave a persuasive explanation for his conclusion. See Nieves-Rodrigeuz v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations include whether the person opining is suitably qualified and sufficiently informed). The VHA expert explained that there was at least a 50 percent probability that the onset of pars planitis, which eventually led to blindness in both eyes, began during active duty service. This conclusion follows from the idiopathic nature of pars planitis, the competent evidence of red or bloodshot eyes at the relevant time, and the fact that the Veteran was within the normal age range for the onset of pars planitis at the time of his service. Given the idiopathic nature of this disease, the precise cause of the Veteran's blindness may never be known with certainty. Therefore, the Board finds that the evidence is approximately evenly balanced as to whether the Veteran's current blindness is the result of an in-service disease, injury or event. By law, the doubt resulting from this relative equipoise in the evidence is resolved in The Veteran's favor. See 38 U.S.C.A. § 5107(b); Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence' . . ., the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits."). III. Increased Rating for PTSD Rating Principles Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations shall be applied, the higher evaluation 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. The Board may consider whether separate ratings may be assigned for separate periods of time - a practice known as "staged ratings," - whether or not the claim concerns an initial rating. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. The relevant criteria authorize a 10 percent rating for occupational and social impairment due to mild and transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is authorized for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." "Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of [occupational and social] impairment." Id. Prior to August 4, 2014, one factor in evaluating psychiatric disorders was the global assessment of functioning scale (GAF). The scale was meant to represent psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM - IV)). Under DSM-IV a GAF score between 41 and 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A score in between 51 and 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). VA regulations were recently amended to remove references to the DSM-IV, and to replace them with references to the Fifth Edition of the same treatise (DSM-5). 79 Fed. Reg. 45,093-02, 45,094 (August 4, 2014). DSM-5 abandoned the global assessment of functioning score as a tool for evaluating the severity of psychiatric disorders. The Veteran filed the pending claim before the effective date of the regulatory change. Since the regulatory change implementing the DSM-5 criteria applies only to applications for benefits received by VA on or after August 4, 2014, the Board may consider any global assessment of functioning scores in the Veteran's treatment records and examination reports. Factual Background In February 2010, after receiving the Veteran's claim for service connection for PTSD, the AOJ arranged for the Veteran to be examined by a VA psychiatrist. The examiner diagnosed chronic PTSD and alcohol dependence, the latter in sustained remission. The Veteran said that he experienced weekly nightmares. It was difficult for him to go to sleep and, according to the Veteran, he slept only two hours during the night and napped throughout the day. The Veteran also said that he avoids crowds and forgets important dates. The Veteran told the examiner that he had four adult children, with whom he is very close. He also said that he had experienced occasional suicidal ideation, but had never attempted suicide. In his interview with the examiner, the Veteran was cooperative and articulate, but his thought process "was highly circumstantial, and he needed to be returned to the questioning on several occasions." He had no suicidal or homicidal ideation at the time of the examination. His mood was slightly anxious and his insight and judgment were fair. The examiner assigned a GAF of 70. In the opinion of the February 2010 examiner, it was at least as likely as not that the Veteran's current psychiatric symptoms were directly related to military sexual trauma. Based on that opinion, the AOJ granted service connection for PTSD and assigned an initial 30 percent rating. The Veteran was examined by another VA psychiatrist in December 2010. The examiner's report was based on a telephone interview with the Veteran and a review of the relevant medical records. The section of the examiner's report concerning the Veteran's present medical history indicated mood swings, anxiety and tension, which caused the Veteran to bite his fingernails. The examiner noted "panicky feelings" but did not believe that these feelings met "the full criteria for a panic attack." The Veteran's speech was clear, spontaneous and coherent. His attitude was cooperative, but his affect was constricted. According to the examiner, the Veteran's thought processes and thought content were unremarkable. The Veteran had no delusions and understood the outcome of his behavior. Like the first examiner, the December 2010 examiner noted sleep impairment. The Veteran told him that he wakes up 5 or 6 times each night and only gets about 4 hours of sleep. He took naps during the day to compensate for his nightly sleep deprivation. The Veteran had no homicidal or suicidal thoughts and his impulse control was described as good. His recent, remote and immediate memories were all normal. According to the examiner, the Veteran experienced intrusive recollections daily, with each episode lasting 30 seconds to 30 minutes. He also experienced mild emotional numbing. The examiner indicated that the Veteran's symptoms affected his ability to concentrate and that, on some days, it was difficult for him to stay focused. The report indicates that the Veteran most recently worked thirteen years before the examination and that visual impairment was the reason he no longer worked. The examiner assigned a GAF of 55. In his opinion, if the Veteran did attempt to work, PTSD symptoms would likely result in reduced reliability and productivity. Based on the examiner's findings, the RO increased the rating for PTSD from 30 percent to 50 percent, with December 8, 2010 (the date of the examination) as the effective date of the increase. After the Veteran complained about the adequacy of the December 2010 report, the AOJ arranged another examination with the same VA psychiatrist, which took place in June 2011. Another purpose of the June 2011 examination was to help decide the Veteran's requests for compensation for two additional psychiatric disorders, described by the Veteran as homophobia and agoraphobia. The Veteran told the examiner that he had some relief from his symptoms since beginning individual psychotherapy. The Veteran told the examiner that he continued to experience sleep deprivation, usually sleeping only two and a half hours during the night and taking naps during the day. According to the examiner, the Veteran's sleep deprivation was the result of circadian rhythm disruption due to blindness. Somewhat inconsistently, in the section of his report labelled "PTSD Symptoms" the examiner listed difficulty falling or staying asleep. The "Medical Opinion" section of the examiner's report provided the following clarification: "Although the disordered sleep [may] in part be related to the posttraumatic stress disorder it is predominantly related to the impairment in circadian rhythms caused by blindness." According to the examiner, PTSD contributed to the quality of the sleep the Veteran experiences, but did not significantly contribute to additional loss of sleep. The Veteran told the examiner that difficulty sleeping was one of the most troubling symptoms. Once again, the examiner wrote that the Veteran's episodes of anxiety did not meet the criteria for a panic attack. Energy and concentration were low. The Veteran had no history of violence or suicide attempts. On examination, the Veteran's speech was spontaneous, clear and coherent. His attitude was cooperative and his affect appropriate. He was oriented to time and place and his thought process was unremarkable. His mood was anxious. According to the examiner, the Veteran did not display inappropriate behavior. He had no homicidal or suicidal thoughts and no obsessive or ritualistic behavior. He had no problems maintaining personal hygiene and his impulse control was good. The examiner described the Veteran's PTSD symptoms as "in the moderate range" and assigned a GAF of 55. The examiner wrote that homophobia was not a DSM-IV diagnosis and that the Veteran's symptoms did not rise to the level of a phobic disorder. Although the Veteran reportedly dislikes traveling and going to town, his symptoms did not meet the criteria for clinical diagnosis of agoraphobia. According to the examiner, the symptoms the Veteran attributed to these claimed conditions are properly understood as manifestations of his PTSD. The most recent PTSD examination was conducted by a VA clinical psychologist in November 2014. The report reflects symptoms of depressed mood, anxiety, panic attacks weekly or less often and chronic sleep impairment. The examiner assigned a GAF of 55. In the examiner's opinion, the Veteran's symptoms were closest to the criteria for a 50 percent rating - i.e., occupational and social impairment with reduced reliability and productivity. The Veteran told the examiner that social activities were infrequent but "some people from church invite me over . . . most [social interaction] is with my children on holidays, father's day. . . but most of the time I spend alone . . ." With respect to occupational and educational history, the examiner indicated that the Veteran had not been employed since 1977. He spent his days listening to "talking books for the blind" and going out to eat. He told the examiner that he has "friends that help me out . . . I have panic attacks, and had an incident when I was cooking, had a panic attack, the spoon caught on fire, and my housecoat caught on fire, and I dropped to the floor and crawled to the door . . ." The Board has also considered the Veteran's post-service psychiatric treatment records during the relevant appeal period. According to a VA psychiatrist's notes, dated August 2009, the Veteran described nightmares and sleeping about 2 hours at a time. He also said that he occasionally feels the need to spend money impulsively - for example by buying hundreds of candy bars for his children. He told the psychiatrist that he avoids gay people because he associates them with his in-service trauma. He denied depressive symptoms and auditory hallucinations. On examination, he was alert and attentive. His grooming was appropriate, though his speech seemed pressured. His mood was dysphoric and his thought process was illogical and characterized by a flight of ideas. A brief suicide risk assessment was negative, and the psychiatrist noted that a more detailed suicide assessment was unnecessary. The Veteran was described as having impulsive judgment and impaired remote memory. Under "insight" the psychiatrist wrote: "none". The psychiatrist assigned a GAF of 50. He met with the same psychiatrist again in September 2009. According to the psychiatrist's notes of that meeting, his speech was much more understandable when compared to his behavior in August 2009. The Veteran also described a more normal energy level, less agitation, improved sleep and better concentration. But speech "is still pressured and he is still jumping from topic to topic and [repeats] questions due to distractibility. He admits to persistence of racing thoughts." The Veteran's mood was neutral and his affect was constricted and irritable. Thought processes were relevant but tangential. The psychiatrist indicated a GAF of 50. A VA mental health outpatient note, dated June 2010, indicated that anxiety symptoms were under reasonable control with medication, but the Veteran continued to have episodic insomnia and daytime lethargy. VA medical records describe another appointment with the Veteran's psychiatrist in June 2010. According to the psychiatrist, the Veteran displayed "pressured speech, flight of ideas, increased psychomotor movements, and expressed very depressed mood, low energy, poor sleep, racing thoughts and hypersexuality." The Veteran's grooming and hygiene were good; his attitude was cooperative. But his motor behavior was agitated and his facial expression was sad. The Veteran's mood was anxious and his affect was constricted. His GAF was 40. A brief suicide risk assessment was negative and no detailed suicide assessment was necessary. According to a February 2011 VA psychology note, the Veteran experienced intrusive recollections daily, lasting from a few seconds to 30 minutes. He also had nightmares four or five times each week. He said that his initial experience with suicidal ideation was in 1968. According to the Veteran, about 20 years ago, when inebriated, his wife embarrassed him in a bar and he responded by pouring a flammable chemical around himself and trying to light it on fire with matches, but it did not burn because there was snow on the ground. "He denied any suicidal ideation, plan or intent since then." On examination, the Veteran was alert and attentive, cooperative and reasonable, his speech was normal. His thought process was normal and coherent and he had no unusual thought content. According to the psychologist a detailed suicide assessment was unnecessary. His GAF was 55. A March 2011 VA psychology note reflects that the Veteran made "very tangential" statements touching on numerous unrelated topics. Veteran's attitude was pleasant and cooperative. His speech was fluent and spontaneous. But his mood was anxious and slightly irritable. He had no suicidal or homicidal ideation, no paranoia or delusions, and no auditory or visual hallucinations. His memory and cognition were grossly intact and his insight and judgment were fair. A VA psychology note from later in March 2011 reported slightly improved symptoms - i.e., thought processes were described as logical and goal-directed. His GAF remained 55. The Veteran's GAF remained 55 according to VA psychology notes from May and June of 2011. In late June 2011, the Veteran was seen by a VA psychiatric nurse practitioner, who assigned a GAF of 48. On examination, the Veteran was alert and oriented, cooperative and reasonable. His speech was normal, though his affect was "blunted/restricted/constricted" and his mood depressed. His thought process was described as normal and coherent but also "disorganized" and "sometimes difficult to follow as he changed from thought to thought." According to the nurse practitioner, the Veteran was not a significant danger to himself or others. On the same day in July 2011, the Veteran had appointments with a VA psychologist and a psychiatric nurse practitioner. The psychologist assigned a GAF of 55 and the nurse practitioner assigned a GAF of 48. The psychologist described the Veteran as having a tangential thought process and a depressed mood. The nurse practitioner wrote that, when the Veteran is worrying, he sometimes sleeps only three hours during the night. She reported that the Veteran was sensitive to medication and "becomes suicidal when he feels he is 'drunk'." However, a suicide risk assessment performed that day indicated that a detailed suicide assessment was unnecessary because the Veteran did not feel hopeless, had no suicidal thoughts in the past week, and had not abused drugs or alcohol in the past week. During August 2011, the Veteran's GAF was 55 according to the psychologist and 48 according to the nurse practitioner. The nurse practitioner wrote that, "Today, he feels like he wants to die because of the level of his anxiety, but he doesn't have a plan as to how he would carry this out." Later in August 2011, the psychologist noted that the Veteran had been depressed because his girlfriend had been stealing from him. After reviewing possible coping techniques, the Veteran told his psychologist that "everything will be okay." He denied hopelessness, suicidal thoughts and alcohol or drug abuse. A September 2011 VA mental health note indicated GAF of 55, with depressed mood and blunted affect. The Veteran's GAF remained 55 according to notes dated December 2011, and January and February 2012. A GAF of 50 was recorded in March 2012. But the Veteran's psychologist noted scores of 55 again in late March, April, May, June and September of 2012. The record does not appear to include GAF scores after September 2012. The Veteran denied suicidal thoughts on at least six occasions between January 2012 and May 2014. A VA primary care note, which is part of his Virtual VA electronic claims file and is dated May 2012, indicated that panic attacks occurred twice each day. In addition to the medical evidence, the Board has reviewed the Veteran's written statements and hearing testimony. With respect to PTSD, most of the information from those sources has already been mentioned in the Board's summary of the medical evidence. In a written statement, received in May 2011, the Veteran described suicidal thoughts shortly after the in-service sexual assault and he said that he communicated these thoughts to a priest. Analysis The medical evidence and lay statements demonstrate that, throughout the relevant appeal period, the Veteran has experienced PTSD symptoms. According to him, the most serious symptoms are panic attacks and trouble sleeping. The June 2011 VA examiner indicated that, although PTSD caused him to have bad dreams, the Veteran's insomnia was caused by the disruption of his circadian rhythms due to blindness. But none of the other VA examiners made a similar finding and the records of the regular psychological treatment suggests that his treating psychologist and nurse practitioner considered insomnia to be a symptom of PTSD. Under these circumstances, attributing the Veteran's insomnia to blindness, rather than PTSD, would be inconsistent with the Board's duty to resolve reasonable doubt regarding the degree of disability in favor of the Veteran. 38 C.F.R. § 4.3. The AOJ assigned a 30 percent rating prior to December 8, 2010 based on the findings of the February 2010 VA examiner. That examiner assigned a GAF of 70, which indicates mild symptoms. However, the remainder of the medical evidence indicates that a GAF of 70 was not typical of the severity of the Veteran's symptoms prior to December 8, 2010. Indeed, the Veteran's treating psychiatrist assigned a GAF of 40 - the lowest score assigned - in June 2010. His other scores usually ranged between 48 and 55. The February 2010 report, moreover, reflects that the Veteran's speech and thought processes were "highly circumstantial, and he needed to be returned to the questioning on several occasions." Circumstantial, circumlocutory, or stereotyped speech are among the criteria for a higher 50 percent rating. See 38 C.F.R. § 4.130. For these reasons, the Board finds that the currently assigned staged rating for PTSD - 30 percent prior to December 8, 2010 and 50 percent since that date - potentially understates the severity of the Veteran's symptoms. Instead, the Board will resolve reasonable doubt in the Veteran's favor and assign a uniform 50 percent rating for PTSD throughout the relevant appeal period. The Board further finds that, throughout the appeal period, the Veteran's symptoms did not more closely approximate the criteria for a higher 70 percent rating. Suicidal ideation is one of the criteria for a 70 percent rating. In July 2011, the Veteran told his treating psychologist that he becomes suicidal when he feels he is "drunk." That note did not indicate how recently the Veteran had been drunk or how recently he had entertained suicidal thoughts. Significantly, a February 2011 psychology note described an incident, which the Veteran said occurred "about 20 years ago" in which he poured flammable liquid around himself and tried to light it on fire. The Veteran told the psychologist, that he "denied any suicidal ideation, plan or intent since then." The record also indicates that, during active duty service, the Veteran told a priest that he wanted to kill himself. Having considered all the evidence, it is clear that these periods of suicidal ideation occurred many years before the start of the relevant appeal period. The incident with the flammable liquid occurred in approximately February 1991 - decades before he submitted an application for benefits for PTSD. Likewise, the statement to the priest must have occurred even earlier - shortly before separation from service in 1968. The VA examiners' reports described the Veteran's alcohol dependence as being in full, sustained remission, which further suggests that the Veteran's suicidal thoughts did not occur at the relevant times. The examination reports and treatment records likewise include more than a dozen occasions on which the Veteran specifically denied suicidal ideation. The Veteran's most serious PTSD symptoms - panic attacks more than once a week, circumstantial, circumlocutory, or stereotyped speech and chronic sleep impairment - all belong to the criteria for 30 or 50 percent disability ratings. There is no evidence that the Veteran's PTSD has ever caused him to engage in obsessional rituals which interfere with routine activities or to display illogical obscure or irrelevant speech. He has not suffered from near-continuous panic or depression affecting the ability to function independently, appropriately or effectively; nor has he displayed impaired impulse control (such as unprovoked irritability with periods of violence). Indeed, his examination reports have noted that the Veteran has never been violent. The evidence does not support the assignment of a 100 percent rating for the Veteran's service-connected psychiatric disorder at any time during the appeal period. A 100 percent rating for a mental disorder requires "total occupational and social impairment . . ." 38 C.F.R. § 4.130. The Veteran has denied hallucinations or delusions and there is no evidence that the Veteran has experienced gross impairment in thought process or communication; disorientation to time or place or memory loss for the names of close relatives, his own occupation or his own name. It is clear from the record that the Veteran's PTSD does not cause him to experience total social impairment; nor that his symptoms prevented him from engaging in normal activities of daily living. In May 2014, the Veteran indicated that he was "planning to write 2 different books and is excited about life." He told the November 2014 VA examiner that he enjoyed listening to audio books and going out to eat. He also described close relationships with his adult children and grandchildren. These statements indicate a degree of occupational and social impairment which is less than total. For these reasons, the Board will grant a higher 50 percent rating for PTSD prior to December 8, 2010, but will deny a rating higher than 50 percent. IV. Blindness Compensation Under 38 U.S.C. § 1151 A Veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) 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 (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. The compensation awarded in the event of a successful § 1151 claim is the payment of compensation "in the same manner as if such additional disability or death were service-connected." Id. The Board has granted service connection for blindness, which means that the Veteran will receive the same degree of compensation as if his § 1151 claim had succeeded. The Veteran filed his initial claim for service connection for blindness in August 2009. He did not raise the theory of compensation under 38 U.S.C.A. § 1151 until January 2010. Accordingly, the § 1151 claim for compensation for blindness, if successful, would not result in the assignment of an earlier effective date for compensation. 38 U.S.C.A. § 5110 (West 2014). In Aronson v. Brown, 7 Vet.App. 153, 155 (1994), the Court applied the jurisdictional restrictions of the case or controversy requirement of Article III of the Constitution of the United States to claims for Veteran's benefits. Relying on Aronson, the Court in Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) determined that the appropriate disposition to a moot claim for TDIU is to dismiss the appeal. Herlehy, 15 Vet. App. at 35. For similar reasons, the Board finds that the Veteran's claim for compensation for blindness pursuant to 38 U.S.C.A. § 1151 is moot and must be dismissed. V. Special Monthly Compensation under 38 U.S.C.A. § 1114 Special monthly compensation (SMC) is a benefit which is paid for certain service-connected disabilities, which result in impairment of the senses, loss or loss of use (of the extremities, creative organ, breast, or buttocks), or which render the Veteran housebound or in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114 (West 2014). While schedular rates of compensation are predicated on the average reduction in earning capacity, special monthly compensation benefits are meant to provide additional compensation based on noneconomic factors such as personal inconvenience, social inadaptability, or the profound nature of the disability. VAOPGPREC 5-89 (Mar. 23, 1989). The Veteran applied for SMC based on his claimed need for the regular aid and attendance of another person, which is a benefit authorized by 38 U.S.C.A. § 1114(l). The record includes evidence suggesting that he requires the regular aid and attendance of another person due to PTSD, blindness, and seizure disorder. SMC at the higher rate authorized by 38 U.S.C.A. § 1114(n) is available for a veteran who, as a result of service-connected disability, has suffered the anatomical loss of both eyes. Because the Veteran's eligibility for this benefit has been raised by the record and granting this benefit, as opposed to SMC under § 1114(l), will result in a greater payment to the Veteran, the Board will grant SMC under § 1114(n). As the Board will explain in the remand section below, he may still be eligible for SMC under § 1114(o) if, as a result of his PTSD or claimed service-connected seizure disorder, he is regularly in need of the aid and attendance of another person. ORDER Entitlement to service connection for blindness is granted. Entitlement to an initial disability rating of 50 percent for PTSD, but no higher, is granted prior to December 8, 2010. Entitlement to an initial disability rating in excess of 50 percent for PTSD is denied. Entitlement to compensation for blindness under 38 U.S.C.A. § 1151 is dismissed. Entitlement to SMC at the rated provided by 38 U.S.C.A. § 1114(n) is granted. REMAND Seizure Disorder The Veteran has submitted multiple written statements requesting disability compensation for a seizure disorder. According to a statement received in August 2012, he began experiencing seizures during his naval service. In the "Code Sheet" section of a rating decision issued in November 2012, the AOJ denied service connection for a seizure disorder. A notification letter, also dated November 2012, indicates that, "We have determined that the following condition [seizure disorder] was not related to your military service, so service connection could not be granted." Liberally construed, a letter submitted by the Veteran in March 2013 amounts to a notice of disagreement appealing the denial of service connection for a seizure disorder. Where, as here, a veteran files a timely notice of disagreement, and VA has not issued a statement of the case, a remand for issuance of a statement of the case is required. Manlincon v. West, 12 Vet. App. 238 (1999). The Board must therefore remand the issue of service connection for a seizure disorder with instructions to issue a statement of the case. As a result of the rulings made by the Board in today's decision, the Veteran has been granted SMC at the rate provided by 38 U.S.C.A. § 1114(n) based on his service-connected blindness with the anatomical loss of both eyes. This does not necessarily resolve his earlier claim for SMC based on the claimed need for aid and attendance of another person. 38 U.S.C.A. § 1114(o) authorizes the payment of additional SMC for conditions entitling the claimant to two or more of the rates (no condition being considered twice) provided in 38 U.S.C.A. § 1114(l) through (n). It is reasonably clear that the Veteran needs the aid and attendance of another person due to his now service-connected blindness. Letters from various medical personnel also indicate that he is potentially in need of aid and attendance due to PTSD and his seizure disorder. But under 38 U.S.C.A. § 1114(o), additional benefits are not available unless the Veteran is entitled to compensation at one of the additional rates without any condition being considered twice, meaning that, to establish his eligibility to receive additional SMC under § 1114(o), his blindness could not be considered. It is not clear whether, in the absence of the Veteran's blindness, his PTSD or his claimed service-connected seizure disorder would make him eligible to receive SMC at one of the rates provided in 38 U.S.C.A. § 1114(l) through (n). Moreover, the remanded claim for service connection for a seizure disorder could potentially affect whether the Veteran is eligible to receive SMC under 38 U.S.C.A. § 1114(o), which means these claims are inextricably intertwined. The appropriate remedy when a pending claim is inextricably intertwined with an issue on appeal is to defer adjudication of the claim on appeal pending the adjudication of the inextricably intertwined claim. See Smith v. Gober, 236 F.3d 1370, 1372 (Fed. Cir. 2001); Henderson v. West, 12 Vet. App. 11, 20 (1998). Accordingly, the case is REMANDED for the following action: 1. The AOJ should conduct any development that may be indicated with respect to the issue of entitlement to SMC at the rate authorized by 38 U.S.C.A. § 1114(o) and service connection for a seizure disorder. The AOJ should consider the potential need for a medical opinion on the issue of whether, in the absence of the Veteran's service-connected blindness, he would still require the regular aid and attendance of another person due to service-connected disabilities. 2. Unless the claim is granted, the AOJ should furnish the Veteran with a Statement of the Case pertaining to the issue of entitlement to service connection for a seizure disorder. This claim should not be returned to the Board unless the Veteran perfects an appeal by filing a timely substantive appeal. 3. After the pending claim for service connection for a seizure disorder has been resolved, the AOJ should review the record and consider the Veteran's eligibility for SMC at the rate authorized by 38 U.S.C.A. § 1114(o). If the benefit sought remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs