Citation Nr: 1756592 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 10-23 588 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for a left eye disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Rachel Mamis, Associate Counsel INTRODUCTION The Veteran had active military service from June 1991 to August 1991, June 1992 to August 1992, October 2001 to March 2002 and September 2001 to July 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. This matter was previously before the Board, most recently in August 2016, at which time the Board remanded the issues currently on appeal for additional development. The case has now been returned to the Board for further appellate action. In his June 2010 substantive appeal, the Veteran requested that he be afforded a hearing before a member of the Board. The Veteran was scheduled for his requested hearing in August 2011. However, in an August 2011 communication, the Veteran withdrew his request for a hearing. FINDING OF FACT A left eye disability preexisted service and did not increase in severity therein. CONCLUSION OF LAW A left eye disability preexisted the Veteran's service and was not aggravated therein. 38 U.S.C. §§ 1131, 1153 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran asserts that his current left eye disability which began prior to service was aggravated thereby. The Veteran's service treatment records (STRs) indicate that the Veteran previously had surgery on his right eye for a retinal hemorrhage in 1989 prior to his first period of enlistment. The Veteran's STRs also indicate that he has worn glasses since the age of 13 for visual acuity correction. At a periodic examination in April 1998, the Veteran indicated on the report of medical history, he had laser surgery on his left eye to prevent problems. The report does not indicate the date of the surgery. The Veteran's visual acuity in the left eye is reported as 20/40. The Board notes that the Veteran receives extensive treatment through private medical providers. Evidence of record from Dr. J.G. indicates that the Veteran underwent laser treatment on his left eye in 1997, which was not during a period of active duty or ACDUTRA. The Veteran was afforded a VA examination in May 2010 in connection with his claim for service connection for a left eye disability. At the time of the examination, the Veteran reported some blurring in his left eye, along with visual disturbances manifested by irregular or distorted images. Upon examination, the revealed, among other things, a macular scar with evidence of old retinal tears. The VA examiner diagnosed macular scars of the left eye due to choroidal neovascular membranes (CNVMs), secondary to presumed ocular histoplasmosis or myopic degeneration. The VA examiner opined that the Veteran's left eye disability was less likely as not caused or aggravated by the Veteran's active service. The examiner reasoned that the Veteran's diagnosed CNVMs can be caused by either the Veteran's ocular histoplasmosis or high myopia, both of which were present and had been treated prior to the Veteran's enlistment in service. The examiner further explained that although the Veteran's left eye CNVMs were diagnosed in service, there is no support in the medical literature for aggravation of this condition by ordinary daily activities, including activities performed in service. He further elaborated that given the Veteran's pre-existing right eye CNVMs, the left eye would have most likely developed the same condition regardless of military service, because it is his pre-existing ocular histoplasmosis and/or high myopia, not the military which pre-disposed him to developing CNVMs. This matter was initially before the Board in March 2015. Pursuant to the March 2015 opinion, the matter was remanded for an addendum opinion. The VA examiner was asked to further identify the nature and etiology of the Veteran's current left eye disabilities. In particular, the examiner was asked to opined as to whether the Veteran's left eye macular scarring, CNVMs, ocular histoplasmosis, myopic degeneration or high myopia were caused by or aggravated by his active service. With respect to the Veteran's myopia, the examiner noted that this condition was present since childhood. As such, it neither had its onset in service, nor was it caused or aggravated by any period of active service. With respect to the Veteran's ocular histoplasmosis, the examiner noted that the condition was first diagnosed in November 1999. He explained that ocular histoplasmosis is most often caused by exposure to the fungus, Histoplasma capsulatum usually during childhood, several decades prior to the onset of histoplasmosis, itself. He noted that those most at risk, live in certain endemic regions in the United States. The Board notes that Arkansas is listed as a region endemic to the Histoplasma fungus. However, he noted that adults exposed to the fungus do not develop histoplasmosis, due to more fully developed immune systems. As such, he explained that the Veteran's ocular histoplasmosis was not incurred in, caused by or aggravated by active service, but rather was caused strictly by exposure to the fungus in childhood. Further, the examiner noted that once exposed, development of retinal scarring and ultimately, vision loss, from histoplasmosis develops along a predictable course beginning approximately 20 years after exposure, and not due to activities later in life. With respect to the Veteran's diagnosed myopic degeneration, the VA examiner stated this condition is congenital, and is directly related to the Veteran's high myopia which was present since childhood. As such, it is not due to any period of active service. He explained that myopic degeneration begins in childhood and develops progressively in stages, as the individual ages. He indicated there is no medical literature to support a worsening of the condition due to the Veteran's activities in service. With respect to the Veteran's left CNVMs the examiner stated that the evidence of record indicates that the Veteran was first diagnosed with this condition in September 2004, following the Veteran's last period of active service. As such, it did not have its onset in service. He further explained that the Veteran's CNVMs were caused either by his ocular histoplasmosis or his myopic degeneration and are a continuum of the Veteran's childhood conditions, and therefore are not caused or aggravated by his period of active service, to include any claimed exposure to mold while in service. Lastly, the VA examiner stated that macular scarring is a natural result of CNVM formation over time. He elaborated that macular scarring due to the previous development of CNVMs itself develops over time, as a result of the natural progression of the CNVM disease process. On that basis, the examiner opined that the Veteran's left eye macular scarring developed sometime between September 2004 and May 2010, as a result of the natural course of the CNVMs diagnosed in the Veteran's left eye in September 2004. He stated that once a CNVM develops, macular scarring is inevitable, even with aggressive treatment and therefore is not due to or permanently worsened by the Veteran's active service, but rather the natural progression of the CNVMs. As noted, this matter was previously before the Board, most recently in August 2016. At the time, the matter was remanded once again for an addendum opinion. The examiner was specifically asked to whether the Veteran's CNVMs, which are the cause of the Veteran's left eye vision loss were aggravated by any period of active duty for training (ACDUTRA). The examiner noted again that CNVMs can be caused by either the Veteran's myopic degeneration or ocular histoplasmosis. Although, he explained that it is not possible to determine, in this particular instance, which condition caused the CNVMs, both conditions developed in childhood, that CNVMs are the natural continuum of these conditions, and therefore were not aggravated by a period of active duty or a period of ACDUTRA. A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air 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 progression of the disease. 38 U.S.C. § 1113 (2012); 38 C.F.R. § 3.306 (a) (2017). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no 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 U.S.C. § 1113 (2012); 38 C.F.R. § 3.306(b) (2017). The medical evidence in this case is unfavorable in terms of attributing any aggravation or exacerbation of the Veteran's current left eye disability to his active service. More specifically, the May 2010, January 2017 and February 2017 opinions did not identify any likely causes of aggravation or exacerbation attributable to the Veteran's periods of active service; and, instead thoroughly explained that any aggravation of the Veteran's CNVMs was due to the natural progression of the Veteran's pre-existing ocular histoplasmosis and/or myopic degeneration. In determining whether there is this required attribution, the examiner provided a rationale with consideration of the Veteran's treatment records, his lay statements, the objective physical examination results, and additional medical research. Thus, the opinion had the proper factual foundation or predicate and is found to be of great probative value. See, Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Based on all the evidence, the Board can now say there is clear and unmistakable evidence against this claim regarding the issue of aggravation. There is now simply overwhelming medical evidence of high probative weight against this claim, not simply meeting, but exceeding this standard. Extensive medical evidence has been collected regarding this issue. In this regard, the Board apologies regarding the delays in the adjudication of this case, but the Board had to insure that all avenues in which this case may be granted were fully considered. Further, while the Veteran may believe that his left eye disability is related to service, he is not competent to link it to incidents or events he experienced in service. Because there is no universal rule as to competence on this issue, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007); see also, Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the etiology of his left eye disability, falls outside the realm of common knowledge of a lay person. See, Kahana v. Shinkseki, 24 Vet. App. at 435; see also, Jandreau v. Nicholson, 492 F .3d at 1377. The Veteran is competent to discuss his symptoms, but he does not possess the experience or specialized training needed to choose which incidents have caused his current left eye disability. Also, his assertions were investigated by competent medical professional and found to be not supportable. Therefore, his lay opinion that his left eye disability is related to his period of service, to include claimed exposure to mold is less probative than the medical evidence of record. The VA examiner, a trained medical professional, thoroughly explained that CNVMs are a common and predictable result of both the Veteran's ocular histoplasmosis and myopic degeneration, and that they were not attributable to, or permanently worsened by the Veteran's service generally, or to his potential exposure to mold in adulthood, specifically. ORDER Entitlement to service connection for a left eye disability is denied. JOHN J. CROWLY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs