Citation Nr: 1801128 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 13-18 737A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to a higher evaluation for cervical spine degenerative joint disease, currently rated at 20 percent. 2. Entitlement to a higher evaluation for hypertension, currently rated at 10 percent. 3. Entitlement to service connection for a bilateral eye condition, including as secondary to service-connected hypertension. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Kathy A. Lieberman, Esq. ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from July 1956 to July 1960. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. This decision denied claims for increased ratings for cervical spine degenerative joint disease and hypertension, along with service connection for a bilateral eye condition. The claim for a TDIU was later filed, and then addressed by the RO pursuant to an October 2017 Supplemental Statement of the Case (SSOC). The Veteran previously had a request for a Travel Board hearing pending, but withdrew that request through correspondence provided in August 2017. The issue of a TDIU is addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does have forward flexion of the cervical spine that is limited to 15 degrees or less. 2. The Veteran's hypertension is manifested by the presence of diastolic pressure that is predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. 3. The evidence is at least evenly balanced on the key question of whether the Veteran's bilateral cataracts are secondarily related to his service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria are not met for a disability evaluation greater than 20 percent for cervical spine degenerative joint disease. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71; 4.71a, Diagnostic Code 5242 (2017). 2. The criteria are not met for a disability evaluation greater than 10 percent for hypertension. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.104, Diagnostic Code 7101 (2017). 3. Resolving reasonable doubt in the Veteran's favor, the criteria are met to establish service connection for bilateral cataracts, secondary to service-connected hypertension. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist With regard to the claimed condition of a bilateral eye disorder, given the Board is granting the instant matter, VCAA discussion is not required, whereas any notice of development deficiency would be harmless error. For the remaining claims for increased ratings, in a July 2017 statement, the Veteran's attorney challenged the adequacy of the March 2017 VA examination for his cervical spine disability in that the examiner did not properly address the presence of upper extremity radiculopathy symptoms. In an October 2017 rating decision the RO granted service connection for radiculopathy of both upper extremities based upon the examination. With regard to the Veteran's cervical spine disability, the examination is adequate because it addressed his current complaints, and because it describes his disability in detail sufficient to allow the Board to make a fully informed determination. Ardison v. Brown, 6 Vet. App. 405, (1994). Neither the Veteran nor his attorney have raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Cervical Spine Degenerative Joint Disease Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40 (2017); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). VA's General Rating Formula for Diseases and Injuries of the Spine provides for the assignment of a 10 percent rating when there is forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of the height. 20 percent is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 30 percent is assigned for forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is for assignment where there is unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, Code 5237. Normal range of motion of the cervical spine is considered forward flexion to 45 degrees, extension to 45 degrees, left and right lateral flexion to 45 degrees, and left and right lateral rotation 80 degrees. 38 C.F.R. § 4.71a, Plate V. Also to be applied pursuant to this case, however, is the Intervertebral Disc Syndrome (IVDS) rating criteria. IVDS is evaluated under the General Rating Formula for Diseases and Injuries of the Spine or otherwise based upon the frequency and severity of its incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The relevant rating formula provides that: If there are incapacitating episodes having a total duration of at least 1 week but less than 2 weeks, a 10 percent rating is warranted; if at least 2 weeks but less than 4 weeks, a 20 percent rating; if at least 4 weeks but less than 6 weeks, a 40 percent rating is warranted; and where there are incapacitating episodes with a total duration of at least 6 weeks during the past 12 months, the assignment of a maximum 60 percent rating is warranted. Note (1) to the IVDS rating criteria provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The record indicates the Veteran filed the instant claim for increased rating in May 2012. On VA examination in June 2012, the diagnosis was degenerative disc disease, cervical spine. The Veteran's stated history was that he hurt his neck while in the military. Per the Veteran, he was in a motor vehicle accident in 1957. He stated he had problems with his neck ever since. The Veteran stated that his neck cracked and was stiff with limited range of motion. The Veteran also complained of a constant throbbing pain (5-10/10) in the back of his neck. The Veteran stated that the pain radiated into both of his shoulders but not into his arms/hands. The Veteran denied any numbness/tingling/weakness in his upper extremities. The Veteran treated his neck pain with muscle relaxers and moist heat (frequent hot showers). The Veteran stated that he had physical therapy in the past but it did not help. There were no flare-ups that impacted the function of the cervical spine. Range of motion measurements indicated that forward flexion was to 30 degrees, extension to 30 degrees, right and left lateral flexion to 20 degrees, right and left lateral rotation 40 degrees. He had pain at all endpoints of motion. The Veteran was able to perform repetitive use testing with three repetitions. After repetitive usage, there was no difference in range of motion. There was functional impairment of the cervical spine after repetitive use, which consisted of less movement than normal, and pain on movement. The Veteran did have localized tenderness and pain to palpation for joints and soft tissue of the cervical spine (neck). There was not guarding or muscle spasm of the cervical spine. Muscle strength was normal. There was no atrophy. Reflexes were normal. Sensory exam was normal. There was no radiculopathy. There were no other neurologic abnormalities related to a cervical spine condition. It was indicated that the Veteran had IVDS of the cervical spine. He had not had any incapacitating episodes over the past 12 months due to IVDS. He did not use any assistive devices. X-rays confirmed cervical spine arthritis. There was no vertebral fracture. There was impact on his ability to work. The Veteran stated that he retired in year 2004. The Veteran stated that he worked long hours as a prison guard and had to do a lot of standing and walking which aggravated his neck. He stated that he occasionally had to miss work due to neck problems and headaches as well as medical appointments. He did not have headaches. He stated that he was currently unable to fish, hunt, or do any other activities that involved bending his neck or lifting. The Veteran stated that he also had difficulty sleeping at night due to his neck problems as well as difficulty driving because of limited range of motion in his neck. X-rays of the c-spine from several years ago in 2005 had shown there was kyphosis of the cervical curvature. There was moderately severe degenerative disc disease at C4-5, C5-6 and C6-7. There were uncinate process spurs resulting in narrowing of the right C4-5, C5-6 and C6-7 neural foramina. The study was unremarkable. According to the Veteran's attorney's August 2016 correspondence, it was indicated that extraschedular consideration was warranted to address the functional limitation to the neck during flare-ups. On March 2017 examination of the cervical spine, the diagnosis was confirmed at outset of cervical spine degenerative joint disease. The Veteran reported an increase in neck pain since his last examination. He described the pain as mostly on the right side. He stated he had some radiating pain to the shoulders and some shoulder numbness of the skin, but no radiation of pain or numbness and tingling to his lower arms and hands. He took Tramadol for neck and lower back pain. The dominant hand was the right hand. The Veteran reported flare-ups of the cervical spine. Sometimes the condition became very painful and caused stiffness of the neck to the extent he could not look up. The Veteran reported functional impairment of the cervical spine, in that it hurt enough on the right side that he could not turn his head much. Range of motion testing indicated forward flexion to 40 degrees; extension to 35 degrees; right and left lateral flexion to 25 degrees; right and left lateral rotation 35 degrees. It was indicated that pain limited functional range. There was pain indicated with regard to movement in extension, right lateral flexion, left lateral flexion, and right lateral rotation. There was no evidence of pain with weight bearing. There was tenderness at the right paraspinal muscles of the cervical spine. The Veteran was able to perform repetitive use testing with at least three repetitions. There was additional loss of function or range of motion after three repetitions. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time, in part because of limited opportunity to observe the Veteran. The examination was not conducted during a period of flare-up. The Veteran did not have guarding, or muscle spasm of the cervical spine. Additional factors contributing to disability were less movement than normal due to ankylosis, adhesions. Degenerative changes and pain limited range of motion. Muscle strength testing was normal. Sensory examination indicated decreased sensation for shoulder area (C5); normal sensation for the inner/outer forearm (C6/T1); normal sensation for the hand/fingers (C6-8). With regard to any radicular pain, the Veteran had mild numbness of the right and left upper extremities. There were no other signs or symptoms of radiculopathy. There was involvement of both C5/C6 nerve roots (upper radicular group). The examiner indicated right and left side radiculopathy, mild level. There was no ankylosis of the spine. There were no other neurologic abnormalities related to cervical spine condition. The Veteran did not have IVDS of the cervical spine. The Veteran did not use any assistive devices. The imaging studies of the cervical spine showed arthritis. The Veteran did not have a vertebral fracture with loss of 50 percent or more of height. The Veteran's cervical spine condition had an impact on his ability to work. According to the VA examiner, the Veteran's service-connected degenerative joint disease of the cervical spine would have a mild to moderate impact upon his ability to perform sedentary occupations, if he were required to maintain a static head posture or was required to bend his neck repeatedly. The Veteran's neck pain and limitation in ROM might limit these activities and would require reasonable accommodations from his employer. The Veteran's condition of degenerative joint disease of the cervical spine would have a mild to moderate impact upon his ability to perform physical activity due to neck pain and limitation in his range of motion. Having reviewed the foregoing, and with application of the VA rating criteria, the claim for increase beyond 20 percent for the Veteran's cervical spine disorder must be denied. In so finding, the primary factor of limitation of motion as due to service-connected cervical spine disability has been considered, but does not warrant any different outcome in this case. As indicated within the relevant General Rating Formula, the next higher rating of 30 percent requires that there be forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. See 38 C.F.R. § 4.71a. The Veteran does not have limited mobility of the cervical spine to that degree. The greatest level of severity indicated was upon 2012 VA examination, whereas the Veteran had 30 degrees of forward flexion. Range of motion was not demonstrably limited based upon any form of functional loss, including pain, weakness, incoordination, or with repetition. Nor for that matter has there been any indication of joint ankylosis, that consisting of a finding of total absence of joint mobility. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). The March 2017 examination noted 40 degrees of forward flexion. Therefore, on the whole, there is not objective substantiation for a greater schedular rating. Even when considering functional loss, the Veteran's ranges of motion are not more accurately described by the 30 percent criteria. Under the General Rating Formula, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment are to be evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula at Note (1). Separate ratings have been granted for radiculopathy to both upper extremities. No additional neurological abnormalities due to the Veteran's cervical spine disability are present. Further considered in this case is the question of entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1), whereas the issue has been directly raised at the request of the Veteran's attorney. See generally, Yancy v. McDonald, 27 Vet. App. 484 (2016). For purpose of extraschedular analysis, the holding from Thun v. Peake, 22 Vet. App. 111 (2008) applies. Under Thun, there is a three-step inquiry for determining whether a Veteran is entitled to an extra-schedular rating. First, the threshold factor for extraschedular consideration is that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. The evidence in this case does not show such an exceptional disability picture. The Board has reviewed the level of severity and symptomatology of the Veteran's service-connected cervical spine disability in connection with the established criteria found in the rating schedule. The existing rating criteria appropriately takes into consideration the limitation of motion due to service-connected disability, and further, to the extent there is any readily demonstrated impact functional loss, those factors are considered by the Board's review and from the findings recorded on the VA medical history. Indeed, "functional limitation" was the very reason that the Veteran and his attorney specifically requested extraschedular consideration, and for the reasons stated the Board does not find this to be a current documented problem. The Board finds that the existing disability rating analysis fairly encompasses the fact that the Veteran has claimed to have developed and manifested a significant degree of functional loss, and there is not a specific subset of functional loss symptoms and manifestations demonstrated or alleged that would otherwise warrant consideration or application of the extraschedular rating provisions. Accordingly, the Board cannot conclude that there is showing of an exceptional disability picture such that rating criteria are inadequate. The first criterion of extraschedular review per the Thun holding not being met here, further analysis is not required, and the Board need not refer this case for an extraschedular rating in accordance with the procedures under 38 C.F.R. § 3.321 (b)(1). The Board notes that the TDIU claim is being remanded. In Brambley v. Principi, 17 Vet. App. 20 (2003), the Court noted that the Board's remand of a TDIU claim for additional record development was inconsistent with a finding that the record was sufficient to conclude that the Veteran's service-connected disability did not produce a marked interference with employment for the purposes of extraschedular consideration. This is distinguishable from this case, where the Board has found that the schedular criteria adequately contemplate the level of the Veteran's cervical spine disability and it need not address whether it results in marked interference with employment. Accordingly, unlike the decision at issue in Brambley, the Board is not maintaining "divergent positions concerning the completeness of the record." See Brambley, 17 Vet. App. at 24. Furthermore, the first and second Thun elements are interrelated but "...involve separate and distinct analyses," and "...the two inquiries are independent." Yancy v. McDonald, 27 Vet. App. 484 (2016). Therefore, the extraschedular consideration can be resolved at this time. This matter is not intertwined with the TDIU claim. Accordingly, the preponderance of the evidence is unfavorable in regard to the outcome of the instant claim for increased rating for cervical spine disorder. Under these circumstances, VA's benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b). Hypertension Hypertension is evaluated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, and is assigned a 10 percent rating for diastolic blood pressure predominantly 100 or more, or; for systolic blood pressure predominantly 160 or more, or; as the minimum evaluation for an individual with a history of diastolic blood pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure of predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. On examination in June 2012 the initial diagnosis was confirmed as hypertension. For medical history, the Veteran stated that he had had high blood pressure "forever." The Veteran stated that he had been on medication for his high blood pressure since the day he was discharged from the military. The Veteran stated that he was taking his medications continuously every day but that his blood pressure was not doing very well. The Veteran was taking as medications for this condition Amlodipine, Lisinopril, Metoprolol. There was no history of a diastolic blood pressure elevation to predominantly 100 or more. Recent blood pressure readings were as follows: September 2011, 140/80; March 2012, 130/90; June 2012 (which was this examination), 138/78. The Veteran's hypertension did not impact his ability to work. The Veteran's attorney stated through September 2013 correspondence, that the Veteran was taking the medications of amlodipine, lisinopril, and metoprolol to treat hypertension. Common side effects of these medications included dizziness, fatigue, nausea, palpitations, headache, diarrhea, weakness, lightheadedness, and shortness of breath. The Veteran's attorney provided argumentation that referral for an extraschedular consideration was warranted to address the symptoms not contemplated within the schedular evaluation and to address marked interference with employment based on side effects of medications. Later in an August 2016 statement, the Veteran's attorney averred having had additional symptoms of dizziness and nosebleeds arising from the service-connected hypertension, which were not adequately addressed in the schedular criteria. The August 2013 letter from private practitioner Dr. A.A. indicates, in relevant part, that the Veteran's blood pressures had been poorly controlled since service. Despite a triple medication regimen, his blood pressures remained marginal. On VA examination in March 2017, the Veteran reported no symptoms due to high blood pressure. His treatment plan included taking continuous medication for hypertension. He took Amlodipine and Lisinopril. There was not a history of diastolic blood pressure elevation to predominantly 100 or more. Blood pressure readings were 173 / 73 from October 2016; 122 /72 from March 2017; 130 / 72 from March 2017. Average blood pressure read was 129 / 72. There were no other pertinent physical findings. The Veteran's hypertension did not impact his ability to work. According to the VA examiner, the Veteran's hypertension would have no impact upon his ability to perform either sedentary or physical employment. The Board finds upon review of the balance of the evidence, that the claim for increased evaluation for hypertension must be denied. Under the pertinent rating criteria, a 20 percent rating is warranted for diastolic pressure of predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Those requirements have not been met, inasmuch as from an objective standpoint, the Veteran does not have the requisite degree and extent of service-connected disability findings that are commensurate with the higher rating requested. As noted above, the evidence shows that the Veteran is prescribed medication to control the hypertension. Whereas arguably the Veteran's blood pressure readings would read out higher without use of such medication, the effects of medication on blood pressure are expressly considered in the rating criteria. See generally, Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). As with the prior service-connected disability reviewed, the Board has again considered the matter of extraschedular rating entitlement under 38 C.F.R. § 3.321(b)(1), per the Veteran's direct request. Applying the framework set forth within the holding within Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extra-schedular rating. The first criterion of extraschedular review per the Thun holding is not met, further analysis is not required, and the Board need not refer this case for an extraschedular rating in accordance with the procedures under 38 C.F.R. § 3.321 (b)(1). Having reviewed the above, however, the Board finds it made sufficiently clear that there has not been provided depiction of an exceptional or unusual disability picture. The primary basis upon which the Veteran's attorney requests thorough consideration and review of extraschedular entitlement, lies with a relatively minimalist symptom set. Namely, the Veteran's attorney has pointed out that the Veteran's hypertension medications are commonly known to produce a series of documented side effects, these being, dizziness, fatigue, nausea, palpitations. However, there is no specific and credible indication that the Veteran has these very symptoms and manifestations himself. They are simply documented side effects, nor has the Veteran actually filed an independent claim for secondary service connection arising out of the same duly noted above-referenced symptomatology. Moreover, the Veteran's attorney had identified the presence of nosebleeds as the consequence of having had hypertension, and while not independently confirmed, the Board does not have direct reason to indicate or suggest that assuming the confirmed existence of this very condition, is of or approaching the severity that it genuinely constitutes and exceptional disability picture. Therefore, the Board finds that the instant claim does not require remand for referral to the office of the VA Director of Compensation for purpose of extraschedular consideration in accordance with 38 C.F.R. § 3.321(b)(1). Brambley is distinguishable from this case, because the Board has found that the schedular criteria adequately contemplate the level of the Veteran's hypertension and it need not address whether it results in marked interference with employment. Accordingly, unlike the decision at issue in Brambley, the Board is not maintaining "divergent positions concerning the completeness of the record." See Brambley, 17 Vet. App. at 24. Furthermore, the first and second Thun elements are interrelated but "...involve separate and distinct analyses," and "...the two inquiries are independent." Yancy, 27 Vet. App. 484. Therefore, the extraschedular consideration can be resolved at this time. This matter is not intertwined with the TDIU claim. On the foregoing grounds, the claim must be denied. Given that the preponderance of the evidence is unfavorable, VA's benefit-of-the-doubt rule is not applicable. Service Connection for Bilateral Cataracts Under applicable VA law, direct service connection is available for current disability resulting from disease contracted or an injury sustained while on active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also may be granted for disease diagnosed after discharge where incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet.App. 247, 253 (1999). If there was chronic disease in service, reappearance at any later date is service-connected, unless clearly due to an intercurrent cause. If not chronic, there must be continuity of symptomatology to link in-service disability to post-service condition. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (continuity of symptomatology principle limited to where involving those diseases already listed as "chronic" under 38 C.F.R. § 3.309(a)). Secondary service connection is available for a condition proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). Secondary service connection also applies when service-connected disability has chronically aggravated a nonservice-connected disability. See 38 C.F.R. § 3.310(b). Whether to award service connection depends on review of all relevant evidence, medical evidence and lay statement, and the evaluation of its competency and credibility. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Based on the current record, there are definitive grounds for awarding service connection for bilateral cataracts, as secondary to the Veteran's service-connected hypertension. The Board recognizes there is a difference in opinion between the 2013 opinion from a private physician, Dr. A.A., and the contrary more recent assessment provided by a March 2017 VA examiner to the effect that the Veteran had a type of cataract that could not be deemed service-connected. All the same, the Board may weigh competing medical opinions, and accomplishes that task in this instance for purpose of establishing a credible and competent linkage between claimed disability, and existing service-connected disability. See Elkins v. Brown, 5 Vet. App. 474, 478 (1993). The August 2013 private physician's opinion first cited to a medical information article published by the Mayo Clinic, indicating in relevant part, that factors that increase one's risk of cataracts included high blood pressure. The physician further indicated: [The Veteran] is currently service-connected for hypertension. His blood pressures have been poorly controlled since service. Despite a triple medication regime, his blood pressures remain marginal. As noted from Mayo Clinic, one of the risk factors for cataracts is high blood pressure. [The Veteran] is also noted have early cataracts in both his eyes. Certainly, since having high blood pressure is a risk factor for cataracts, then poorly controlled blood pressure only increased the risk. Therefore, it is my medical opinion that it is more likely than not that the Veteran's service-connected hypertension, which is poorly controlled, has contributed to his early bilateral cataract formation. On VA Compensation and Pension examination March 2017, with regard to cataracts, the opinion given was: [Cataracts] The condition claimed is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. Rationale: The Veteran has nuclear sclerotic cataracts OU which are consistent with what would be expected for his age. Dr. Ali's letter dated 8/7/2013 includes information from the Mayo Clinic website indicating that hypertension can be a risk factor for certain types of cataracts. A 5-year follow-up of 2454 people in the Blue Mountains Eye Study showed a three-fold increase of posterior subcapsular cataract incidence among participants using antihypertensive medications. No association was found with nuclear cataracts. Given that this Veteran has only nuclear-type cataracts, we cannot conclude that hypertension caused or aggravated his condition. [Subconjunctival hemorrhage] The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service-connected condition. Rationale: A letter from the Veteran's attorney dated 8/8/16 also states that they believe veteran should be service connected for "residuals of the subconjunctival hemorrhage." The Veteran does have a history of subconjunctival hemorrhage OS in 2016. This was a self-limiting condition, much like a bruise, and has since resolved without any residual sequelae. The American Academy of Ophthalmology states, "The most common causes [of subconjunctival hemorrhage] are coughing, sneezing, straining, or any similar action that temporarily raises blood pressure in the veins, leading to a small rupture in a blood vessel or capillary. Subconjunctival hemorrhage can also occur because of trauma to the eye - even minor trauma such as rubbing the eye vigorously. Other common but less frequent causes of subconjunctival hemorrhage include diabetes mellitus, high blood pressure, and excessive amounts of certain medications such as aspirin or blood thinners like warfarin, which affect the body's bleeding mechanisms." At his exam 2/4/16, the veteran did not note any history of trauma, coughing, or straining. He was taking daily aspirin and his more recent blood pressure reading in his chart was from 1/27/16 and was 134/69. There is no way to know for certain what caused the subconjunctival hemorrhage, but hypertension is a risk factor for this self-limiting condition. The VA medical opinion may be the best-reasoned in regard to the cataract condition, particularly given that the opinion appropriately distinguishes between two types of cataracts, finding the Veteran's nuclear sclerotic cataracts not to be of the variety that undergoes initial causation, or, chronic aggravation, as the consequence of hypertension. However, the 2013 private medical opinion finds otherwise, indicating that irrespective of the type of cataract that hypertension is a known and significant risk factor the development of cataracts in this particular situation. Whereas the VA examiner made an important distinction insofar as the type of cataracts manifested and how that impacts the determination of the potential clinical relationship to already service-connected hypertension, the Board is mindful that the Dr. A.A., clearly considered the entire documented VA medical record, and further, notated what appeared to be a very significant history of highly elevated blood pressure well prior to when the condition was controlled with medication. Taking these additional factors into account indicated by the evaluating private physician, the Board considers the evidence at least in relative equipoise in regard to the question of whether the Veteran's bilateral cataracts are secondarily related to his service-connected hypertension. Where the evidence is evenly balanced, upon a case dispositive issue, the Board must resolve reasonable doubt in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). For the reasons indicated, there are ground to find secondary service connection established for bilateral cataracts. Accordingly, the is granted. ORDER The claim for a disability evaluation greater than 20 percent for cervical spine degenerative joint disease is denied. The claim for a disability rating higher than 10 percent evaluation for hypertension is denied. Service connection for bilateral cataracts as secondary to service-connected hypertension is granted, subject to the law and regulations governing the payment of VA compensation benefits. REMAND Given the above grant of service connection for cataracts, and that the most recent VA examination for the cervical spine region did not fully take into account employability in association with the Veteran's service-connected right and left upper extremity radiculopathy, a VA general medical examination in regard to the Veteran's TDIU claim is warranted Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for VA general medical examination regarding his TDIU claim. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. Based on a review of the claims file, the examiner must provide a functional assessment of each of the Veteran's individual service-connected disabilities on his ability to work, without consideration of his age or nonservice-connected disabilities. A complete rationale is requested from the examiner for all opinions that are provided. 2. Then readjudicate the claim on appeal for TDIU in light of all additional evidence received. If the benefit sought on appeal is not granted, the Veteran and his attorney should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs