Citation Nr: 1801390 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 13-32 775 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a skin condition, to include as due to herbicide exposure. 2. Entitlement to service connection for a condition manifested by numbness, tingling, and tremor of the hands, to include as due to herbicide exposure. 3. Entitlement to service connection for a condition manifested by dizziness, to include as due to herbicide exposure. 4. Entitlement to service connection for a bilateral eye condition, to include as due to herbicide exposure. REPRESENTATION Veteran represented by: Mississippi State Veterans Affairs Board WITNESSES AT HEARING ON APPEAL Veteran; Veteran's spouse ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1967 to November 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Veteran and his wife appeared at a hearing before a Decision Review Officer (DRO) in February 2015, a transcript of which is associated with the claims file. In July 2016, the Board remanded this matter for further development. The Board notes that the Veteran was denied entitlement to service connection for posttraumatic stress disorder (PTSD) in an August 2015 rating decision. In a September 2017 response to the supplemental statement of the case for the issues currently on appeal, the Veteran indicated that he "had a PTSD test" and that he did not "recall hearing a decision on this." To the extent that he seeks to reopen his PTSD claim, the Board encourages him file a claim with the RO. The issue of entitlement to service connection for a skin condition is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's exposure to herbicide agents is presumed. 2. The Veteran is not shown to have acute or subacute or early onset peripheral neuropathy; a condition manifested by tingling, numbness, and tremor of the hands became manifest many years after his active service and is not attributable to an in-service disease or injury, to include exposure to herbicide agents therein. 3. A condition manifested by dizziness became manifest many years after the Veteran's active service and is not attributable to an in-service disease or injury, to include exposure to herbicide agents therein. 5. The Veteran has not been diagnosed with an eye condition other than refractive errors, and there is no evidence of aggravation or an additional disability of the eyes superimposed on such refractive errors that is related to military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a condition manifested by tingling, numbness, and tremor of the hands have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for entitlement to service connection for a condition manifested by dizziness have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for entitlement to service connection for a bilateral eye condition have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.9 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under applicable law, 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, 3.326(a) (2017). In the present case, VA's duty to notify was satisfied by way of an October 2010 letter to the Veteran. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. The Veteran has not identified any outstanding evidence, to include any other medical records, which could be obtained to substantiate his appeal. Additionally, the Board finds that there has been substantial compliance with its previous remand directives, to include obtaining outstanding records, providing the appellant with VA examinations, and obtaining etiology opinions. In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131; 38 C.F.R. 3.303(a). Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). In general, service connection requires evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A Veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, is presumed to have been exposed to certain herbicide agents (e.g., Agent Orange) during such service, absent affirmative evidence to the contrary. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Service connection based on herbicide agent exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Even if a Veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide exposure, VA must also consider the claim on a direct service-connection basis. When a disease is first diagnosed after service but not within the applicable presumptive period, service connection may nonetheless be established by evidence demonstrating that the disease was in fact incurred in service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). In deciding the Veteran's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or, whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. A. Tingling, Numbness, Tremor of Hands and Dizziness The Veteran contends that he has a condition manifested by tingling, numbness, and tremor of the hands and a condition manifested by dizziness as a result of his exposure to herbicides during service in Vietnam. The Veteran's service treatment records show no complaints of or treatment for either dizziness or tingling, numbness, or tremor of the hands at any time during active service. During an October 1970 discharge examination, the Veteran's neurologic system was evaluated as clinically normal. During an October 2002 VA new patient evaluation, the Veteran denied dizziness, numbness, and tingling. Thereafter, he denied dizziness, numbness, and tingling during VA primary care visits in August 2003, August 2004, and August 2005. An August 2006 VA treatment record shows that the Veteran reported occasional dizziness with no other symptoms. He was diagnosed with recurrent vertigo. Thereafter, he denied dizziness, numbness, and tingling during VA primary care visits in September 2009, July 2010, and April 2011. A July 2012 VA treatment record shows that the Veteran had a very mild essential tremor to the left hand. During a February 2015 DRO hearing, the Veteran testified that tingling in his hands started four to five years previously. He also reported "nervousness" of his hands and a loss of grip strength. Regarding dizziness, the Veteran testified that he first experienced dizzy spells in 1974. The Veteran testified that he currently had dizzy spells three to four times per week in which he felt lightheaded. He also testified that he did not have dizzy spells on active duty. The Veteran's wife testified that she saw the Veteran having dizzy spells about once a week after they were married. The Veteran also stated his belief that all of his problems started with Agent Orange. The Veteran was afforded a VA peripheral nerves condition examination in November 2016. The Veteran reported intermittent tingling of the hands to mid-forearm and intermittent tremor. He also reported some numbness in the fingertips. He indicated that the symptoms last 10 minutes, at most, and reoccur two to three times per month. The Veteran also reported intermittent dizziness, which he described as lightheadedness. He indicated that the dizzy spells last up to an hour or two and reoccur twice a week. On examination, the Veteran had normal motor strength, with normal tone, bulk, dexterity, and coordination. Reflexes were trace to 1+ and equal. He had a mild postural tremor right greater than left. The examiner indicated that the veteran had "subjective sensory complaints of numbness, tingling, and dizziness without any evidence of peripheral nerve disease." The examiner opined as follows: With respect to the numbness and paresthesias, the long interval (30 years) between exposure to herbicide and onset of sensory disturbance makes any associate between the two speculative. His dizziness might have a closer relationship, but 4 years is also a long time to allow any confidence of an association between it and herbicide exposure. The dizziness he describes appears to be blood pressure related, particularly given a history of syncope in the past (pre-syncope and syncope). I am unaware of any proven relationship between herbicide exposure and altered blood pressure control. In June 2017, the Veteran submitted an internet article entitled "Symptoms of Agent Orange in Vietnam Veterans." The article stated that tingling, numbness, and loss of sensation are symptoms related to the neurological impact of Agent Orange exposure. In a September 2017 addendum, the November 2016 VA examiner indicated that he had further reviewed the Veteran's lay statements and treatise evidence regarding dizziness, tremor, and tingling of the hands. The examiner opined that the Veteran's conditions were less likely as not related to service. The examiner noted that the treatise evidence submitted by the Veteran "catalogues a list of symptoms reported by Veterans exposed to agent orange including mental issues, blurry vision, memory loss, numbness, headaches, and twitching." The examiner acknowledged that "[s]cientific research has shown that there is limited or suggestive evidence that exposure to agent orange may cause peripheral neuropathy with onset within months of exposure," however, the examiner also indicated that there was no scientifically proven or suggested association of dizziness with Agent Orange exposure. With respect to numbness and paresthesias, the examiner indicated that "the long interval (30 years) between exposure to agent orange and onset of sensory disturbance makes any associate between the two speculative" because the scientific literature only supports a possible association when symptoms begin within months of exposure. The examiner noted that the Veteran's complaints of dizziness "might have a closer temporal relationship," but indicated that four years is also a long time to allow any confidence of an association between it and herbicide exposure. The examiner also indicated that "there is no scientific evidence that links agent orange exposure with dizziness," and that the dizziness described by the Veteran appeared to be blood pressure related. After review of the foregoing evidence, the Board finds that service connection for condition manifested by tingling, numbness, and tremor of the hands and a condition manifested by dizziness is not warranted. The Veteran's service records show that he served in the Republic of Vietnam. The Veteran is therefore presumed to have been exposed to Agent Orange or other herbicide agents. See 38 C.F.R. § 3.307 (a)(6)(iii). However, neither vertigo or another condition manifested by dizziness is listed as one of the disabilities for which presumptive service connection based on herbicide exposure can be granted under 38 C.F.R. § 3.307 (a)(6) and 38 C.F.R. § 3.309 (e). Regarding a condition manifested by tingling, numbness, and tremor of the hands, the Board notes that certain types of peripheral neuropathy are diseases that are presumptively associated with herbicide exposure. 38 U.S.C.A. § 1116 (a)(2); 38 C.F.R. § 3.309 (e). The regulations formerly referred to "acute and subacute" peripheral neuropathy; however, effective September 6, 2013, VA amended its regulations regarding presumptive service connection for acute and subacute peripheral neuropathy. Specifically, based on findings from the September 29, 2010 National Academy of Sciences report titled, Veterans and Agent Orange: Update 2010, which concluded that early-onset peripheral neuropathy associated with herbicide exposure is not necessarily a transient condition, the amendment replaced the terms "acute and subacute" in 38 CFR § 3.307 (a)(6)(ii) and 38 CFR § 3.309 (e) with the term "early-onset" and removed the Note to 38 CFR 3.309 (e) requiring that the neuropathy be "transient." This change effectively removed the requirement that acute and subacute peripheral neuropathy appear "within weeks or months" after exposure and that the condition resolve within two years of the date of onset in order for the presumption to apply. Thus, to qualify for presumptive service connection, early onset peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a). In the present case, the record does not reflect a diagnosis of peripheral neuropathy at any time, much less to a degree of 10 percent or more within a year of the Veteran's presumed exposure to herbicides. Moreover, the evidence does not show, nor has the Veteran asserted, that tingling, numbness, and tremor of the hands manifested within one year after his last exposure to herbicides. As noted above, the Veteran reported that his symptoms started in approximately 2010, which is 30 years after service. Accordingly, service connection may not be granted on a presumptive basis based on herbicide exposure. The Veteran is therefore not entitled to invoke these presumptions but his claim is still considered under traditional service connection principles. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). As an initial matter, there is evidence of a disability manifested by dizziness, vertigo, which was diagnosed in August 2006. Although there is no diagnosis of vertigo during the pendency of the current claim (i.e., since 2010), the Veteran is competent to report that he continues to experience dizziness. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board notes that the Veteran is competent to report such symptoms as they are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran has given no reason for the Board to doubt his credibility in this regard. Similarly, although there is no formal diagnosis of a peripheral nerve condition, the Veteran has competently and credibly testified that he has numbness and tingling in his hands, and essential tremors were noted during VA treatment in July 2012 and during the November 2016 VA examination. As such, the Board finds the current disability element is established as to both a condition manifested by dizziness and a condition manifested by tingling, numbness, and tremor of the hands. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, the Veteran's herbicide exposure is presumed. Thus, there is evidence of an event, injury, or disease in service. Accordingly, the issue turns upon whether there is evidence of a nexus between the in-service event and the present disability. Id. Upon review of the foregoing evidence, the Board concludes that the weight of the evidence of record is against a finding that the Veteran's conditions are related to any injury, event, or illness in service, to include his presumed herbicide exposure. As noted above, service treatment records do not contain references to a diagnosis of, or treatment for, a condition manifested by dizziness or a condition manifested by tingling, numbness, and tremor of the hands, and the Veteran's neurologic system was clinically normal upon discharge. Post-service, the Veteran testified that his dizziness started in 1974, which was four years after service discharge, and that his tingling, numbness, and tremor started 30 years after service. Moreover, the Veteran does not contend that these disabilities first manifested during service or shortly after service. The Veteran has never contended that any aspect of service other than exposure to herbicides was applicable in his case and none of his attending clinicians noted reports by the Veteran of any symptoms or events in service relevant to the conditions. Thus, there is no medical or lay evidence that such conditions manifested during active service or until many years thereafter. Regarding a nexus to service, the Board finds the November 2016 VA opinion and September 2017 addendum to be highly persuasive to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the VA examiner's conclusions are shown to have been based upon a review of the Veteran's claims file, physical examination, and acknowledgement of the Veteran's lay statements regarding the onset and continuity of his symptoms. Moreover, the opinion is supported by a sufficient explanation and reference to pertinent evidence of record, including the treatise evidence submitted by the Veteran. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report "must be read as a whole" to determine the examiner's rationale). Furthermore, the conclusions are consistent with the evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion ... that contributes probative value to a medical opinion"). Additionally, the opinion did not merely rest on the fact that the Veteran's conditions are not presumptively linked to Agent Orange exposure. Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009). In this regard, the examiner reviewed the literature, noted the limitations in the studies regarding relationships between the diseases and herbicide exposure, and discussed the studies in relation to the Veteran's medical history. The examiner cited several factors, to include the time lapse between service and the onset of symptoms, the Veteran's hypertension diagnosis, and an absence of relevant treatment or complaints in the service treatment records in support of his negative determination. Because the examiner had an accurate history, medical expertise and training, and provided a sound rationale for the medical opinion, the November 2016/September 2017 VA medical opinion is of significant probative value and weighs against a finding that the Veteran's claimed conditions are due to service, to include herbicide exposure therein. The Board acknowledges the Veteran's contention that he developed his claimed conditions due to in-service herbicide exposure. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the diagnosis and etiology of the Veteran's claimed conditions falls outside the realm of common knowledge of a lay person. A determination as to the cause of the Veteran's dizziness and tingling, numbness, and tremors would require interpretation of medical research and literature. While the Veteran can competently report events in service and his symptoms, any opinion regarding whether his claimed conditions are related to his presumed herbicide exposure requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). Hence, his assertions in this regard have no probative value. The Board also acknowledges the treatise evidence submitted by the Veteran. A treatise "can provide important support when combined with an opinion of a medical professional" if the treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998) (medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus); 38 C.F.R. § 3.159 (a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). Here, the treatise provided by the Veteran is very general in nature and does not contain any information or analysis specific to the Veteran's case or the circumstances of his own disability. As discussed by the VA examiner, the internet article merely catalogues some of the possible health effects of herbicide exposure, but the article does not indicate the likelihood of such a link or causation. The treatise evidence submitted by the Veteran provides only general information rather than a generic relationship with a degree of certainty such that, under the facts of this specific case, there is at least plausible causality between the Veteran's injury in service and the later development of his claimed conditions. The Court has held on several occasions that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See generally Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611(1992). Further, the treatise evidence submitted by the Veteran is not accompanied by the opinion of any medical expert to link the speculation in the article to the specific facts of the Veteran's case. To the contrary, the September 2017 VA examiner reviewed the treatise evidence and opined that it did not reflect data showing that the Veteran's claimed conditions were related to his presumed herbicide exposure. There can be no doubt from review of the record that the Veteran rendered honorable and faithful service for which the Board is grateful. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted. Accordingly, the Board finds that the claim of entitlement to service connection for a condition manifested by tingling, numbness, and tremor of the hands and a condition manifested by dizziness must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Bilateral Eye Condition The Veteran seeks service connection for a bilateral eye condition, claimed as "blurred vision." Service treatment records are silent for complaints or treatment related to the eyes. During an October 1967 enlistment examination, the Veteran's was 20/20. His vision was also 20/20 during an October 1970 discharge examination. During a February 2015 DRO hearing, the Veteran testified that his blurred vision started six to seven years previously. The Veteran was afforded a VA eye conditions examination in November 2016. The Veteran reported onset of bilateral blurred vision seven or eight years previously, and he reported that his VA doctor told him his eyes were getting weaker due to his age. After examination, the Veteran was diagnosed with hyperopia, astigmatism, and age-related presbyopic refractive error. The examiner indicated that "[t]here is no decrease in the [V]eteran's visual acuity or other visual impairment." The examiner also noted that medical literature did not show that blurred vision was a symptom of, associated with, or related to herbicide exposure. Refractive errors, including astigmatism, myopia, hyperopia, and presbyopia, are considered congenital defects. See M21-1 Part III, Subpart iv, 4.B.1.d. Generally, congenital defects are not diseases for VA compensation purposes. 38 C.F.R. § 3.303 (c); see also 38 C.F.R. § 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996). In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects or refractive errors of the eyes, even if visual acuity decreased in service, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for either a congenital defect or a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury that created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (July 18, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Thus, in the absence of some event or trauma, a refractive error is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. §§ 3.303 (c), 4.9 (congenital or developmental defects, refractive error of the eye, personality disorders, and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); see also VAOPGCPREC 82-90. VA's General Counsel issued an opinion interpreting 38 C.F.R. § 3.303 (c) to mean that that service connection may be granted for diseases of congenital, developmental, or familial origin if the evidence as a whole shows that manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 67-90. The VA General Counsel also has issued an opinion that a congenital defect can be subject to superimposed disease or injury, and, if superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. In the instant case, the November 2016 VA examiner found that the Veteran did not have an eye disorder other than refractive errors. Moreover, there is no evidence of an event or trauma to the eyes in service. As such, there is no evidence that the Veteran's refractive errors were aggravated or subject to a superimposed disease or injury during his military service that resulted in additional disability. Service treatment records are silent with respect to any complaints or injuries to the eyes and his vision was 20/20 at discharge. Thus, as the Veteran's current eye disorders are considered congenital or developmental defects of the eyes and not a disease or injury within the meaning of applicable legislation relating to service connection, service connection may not be allowed. Accordingly, the Board must deny the claim as the Veteran does not meet the criteria for service connection, namely, a presently diagnosed disability within the meaning of the term "disability" for VA compensation purposes. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C.A. § 5107; Gilbert, 1 Vet App. 49; 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a condition manifested by numbness, tingling, and tremor of the hands is denied. Entitlement to service connection for a condition manifested by dizziness is denied. Entitlement to service connection for a bilateral eye condition, to include astigmatism, hyperopia, and presbyopia, is denied. REMAND After a careful review of the Veteran's claims file the Board finds that further development is required prior to adjudicating the issue of entitlement to service connection for a skin condition. The Veteran's main contention is that he has a skin condition as a result of herbicide exposure. However, his service treatment records show treatment for non-specific dermatitis and fungal infection of his feet. During a February 2015 DRO hearing, the Veteran testified that he first noticed a skin rash right after he was discharged from service. The Veteran's wife testified that she saw the skin rash before she married the Veteran in 1976. Post-service treatment records show diagnoses of hyperpigmentation to the trunk and arms, eczema, dermatitis, xerosis, and seborrheic keratosis. The Veteran was afforded a VA skin examination in September 2011. He reported developing a rash over his entire body while in service that he attributes to Agent Orange exposure. The Veteran reported "a continuation of the rash from when he was on active duty." He stated that the rash will go from one part of his body to another, and that, within a month, the rash will "float to his back, chest, legs, or arms." The examiner diagnosed the Veteran with contact dermatitis and opined that it was not related to the dermatitis condition shown in service. As noted in the July 2016 remand, the examiner did not provide a rationale for this finding or discuss the Veteran's reports of experiencing an intermittent skin rash since service. Accordingly, the Board directed that the Veteran be provided with a new VA examination for the purpose of ascertaining the nature and etiology of all current skin disabilities. The Veteran was afforded a VA examination in November 2016. The examiner noted that the Veteran had been diagnosed with seborrheic dermatitis, which is "a chronic, relapsing and usually mild dermatitis." The examiner summarized the Veteran's service treatment records and post-service treatment records, and the examiner opined that "this is less likely as not the same skin condition the [V]eteran was treated for while in service." However, again, the examiner provided no rationale for this opinion. Upon review, the Board finds that the November 2016 opinion is not fully responsive to the questions specified in the June 2016 Board remand. A remand by the Board confers on a claimant, as a matter of law, the right to compliance with the remand orders and provides that the Secretary of VA has a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268 (1998). In this regard, the examiner did not fully discuss the Veteran's lay statements regarding symptoms since service. Moreover, the examiner's opinion that the Veteran's current skin condition is not the same as the skin condition in service is conclusory and unsupported by any explanation of rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight); Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Accordingly, on remand, an addendum medical opinion should be obtained. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence...is essential for a proper appellate decision"); 38 C.F.R. § 4.2 (noting that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). Lastly, as the record reflects that the Veteran receives ongoing VA treatment, any relevant, updated treatment records should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file all outstanding VA treatment records for the period from April 2017 to the present, documenting treatment for the issue on appeal. The Veteran should also be given the opportunity to identify and/or submit any additional private treatment records pertinent to his claim. 2. After all available records have been associated with the claims file, obtain an addendum opinion regarding the nature and etiology of any and all skin conditions diagnosed proximate to, or during the pendency of, this appeal. The claims file and a copy of this REMAND must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. If an examination is deemed necessary in rendering the addendum opinion, another evaluation should be conducted. Following a review of the claims file, and if necessary an examination of the Veteran, the reviewing examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that a current skin condition, to specifically include hyperpigmentation to the trunk and arms, eczema, dermatitis, xerosis, and seborrheic keratosis, had its onset in service or is related to any in-service disease, event, or injury, to include service treatment records showing treatment for dermatitis, fungal infection and immersion foot, as well as the Veteran's competent reports of having intermittent skin rashes since service. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical sciences as applicable to this case, which may reasonably explain the study of this case. 3. After the above development has been completed, review the file and ensure that all development sought in this REMAND is completed. Arrange for any further development indicated by the results of the development requested above, and then re-adjudicate the claims. If benefits sought on appeal remain denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs