Citation Nr: 1803893 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 12-32 347 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for right hand paresthesia/neuropathy, to include as due to a qualifying chronic disability to include undiagnosed illness. 2. Entitlement to service connection for left hand paresthesia/neuropathy, to include as due to a qualifying chronic disability to include undiagnosed illness. 3. Entitlement to an initial disability rating for right eye macular pucker, in excess of 0 percent from October 1, 2010 to July 13, 2016, and in excess of 10 percent from July 13, 2016. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran (Appellant) and spouse ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from July 1979 to June 1984, and from July1990 to September 2010. This appeal comes to the Board of Veterans' Appeals (Board) from July 2011, September 2012, and August 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, and Roanoke, Virginia. The current agency of original jurisdiction (AOJ) is the VA RO in Roanoke, Virginia. Claims for service connection for macular defect, right eye/puckering and paresthesia in both hands were received in August 2010. The July 2011 rating decision, in pertinent part, granted service connection for right eye macular pucker and assigned a noncompensable (0 percent) initial disability rating effective October 1, 2010 (the day after the Veteran's separation from active service). The September 2012 rating decision denied service connection for paresthesia/neuropathy of the right and left hands. The August 2016 rating decision granted a 10 percent disability rating for the right eye macular pucker effective July 13, 2016, creating "staged" initial disability ratings. VA is bound to consider all pertinent theories of service connection, whether or not a theory is raised by the veteran. See Schroeder v. West, 212 F.3d 1265 (Fed. Cir.2000) (holding that a claim for disability compensation should be broadly construed to encompass all possible theories of entitlement). As discussed below, the Veteran had service in the Southwest Asia Theater of operations during the Persian Gulf War. With respect to the issue of service connection for right and left hand paresthesia/neuropathy, the Board finds that the evidence of record at least reasonably raises the theory of presumptive service connection as due to a qualifying chronic disability to include undiagnosed illness under 38 U.S.C. § 1117 (2012) and 38 C.F.R. § 3.317 (2017); therefore, the Board has recharacterized this issues on the title page to reflect consideration of this presumptive service connection theory. In February 2017, the Veteran and spouse testified at a Board videoconference hearing at the local RO in Roanoke, Virginia, before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of the hearing is of record. FINDINGS OF FACT 1. The Veteran had service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran has current qualifying chronic disabilities characterized by symptoms of right and left hand numbness and paresthesia that have manifested to a compensable degree during a six month period since service. 3. For the entire rating period from October 1, 2010, the right eye macular pucker has been manifested by corrected distance vision of 20/70 in the right eye, distorted and blurred vision, and sensitivity to light, with no incapacitating episodes, abnormalities in muscle function, or contraction or loss of visual field. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for presumptive service connection for undiagnosed right hand numbness and paresthesia as due to a qualifying chronic disability have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for presumptive service connection for undiagnosed left hand numbness and paresthesia as due to a qualifying chronic disability have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 3. Resolving reasonable doubt in favor of the Veteran, for the initial rating period from October 1, 2010 to July 13, 2016, the criteria for an initial disability rating of 10 percent for right eye macular pucker have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.75, 4.76, 4.76a, 4.77, 4.78, 4.79, Diagnostic Code 6006-6066 (2017). 4. The criteria for an initial disability rating in excess of 10 percent for right eye macular pucker have not been met or more nearly approximated for any part of the initial rating period from October 1, 2010. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.75, 4.76, 4.76a, 4.77, 4.78, 4.79, Diagnostic Code 6006-6066 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159 (2017). VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017). Such notice should also address VA's practices in assigning disability ratings and effective dates for those ratings. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board is granting service connection for undiagnosed right and left hand numbness and paresthesia, constituting a full grant of the benefit sought on appeal; therefore, there is no further VCAA duty to notify or assist, or to explain compliance with VCAA duties to notify and assist, with respect to these issues. With respect to the issue of higher initial disability ratings for right eye macular pucker, in this case, notice was provided to the Veteran in August 2010, prior to the initial adjudication of the claim in July 2011. The Veteran was notified of the evidence not of record that was necessary to substantiate the claim, VA and the Veteran's respective duties for obtaining evidence, and VA's practices in assigning disability ratings and effective dates. Further, this issue comes before the Board on appeal from the decision which also granted service connection; therefore, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C. § 5103(a) notice for the service connection claim that was granted. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records, service personnel records, private treatment records, VA examination reports, a copy of the February 2017 Board hearing transcript, a June 2017 Veterans Health Administration (VHA) medical opinion report, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Indeed, even when the adequacy is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). With respect to the right eye macular pucker, the Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in September 2010 and July 2016. Throughout the course of the appeal, the Veteran has contended that the VA examiners did not have the appropriate equipment to confirm or establish the diagnosis of macular pucker. See e.g., February 2017 Board hearing transcript at 17-18; see also November 2012 notice of disagreement (contending that the 2010 VA examiner performed a basic eye exam to check for glaucoma and visual acuity). In a September 2016 written statement, the Veteran contended that tomography was not performed during the VA examinations, but rather a basic eye examination - the Veteran contends that the testing performed was not sufficient to diagnosis retinal disorders such as macular puckering. See also February 2017 written statement. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that a claimant challenging the expertise of a VA physician must "set forth the specific reasons . . . that the expert is not qualified to give an opinion." Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010). That has not happened in this case. The Veteran has disputed the adequacy of the testing performed during the VA examinations, but has not provided a specific argument or evidence concerning the professional competence of the VA examiners; therefore, the examiners are presumed competent to conduct the examination. See Rizzo, 580 F.3d at 1290-1291. With respect to the Veteran's contention that the VA examinations were inadequate due to lack of appropriate or specialized testing equipment, service connection for right eye macular pucker has already been established. As such, it is the severity of the disability throughout the appeal period that is at issue rather than the diagnosis for which service connection has already been established. Under the General Rating Formula for Diagnostic Codes 6000 through 6009 (the eye disability in this case is rated under Diagnostic Code 6006), eye disorders are rated on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher rating. 38 C.F.R. § 4.79. Review of the VA examination reports reflects that testing with respect to visual impairment was conducted and notations with respect to incapacitating episodes were recorded. The Board finds that the September 2010 and July 2016 VA examination reports are thorough and adequate and provide a sound basis upon which to base a decision with regard to the initial rating issue decided herein. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, conducted physical examinations, and specifically addressed the symptoms and impairment listed in the relevant rating criteria under the potentially applicable diagnostic codes. Further, at the February 2017 Board hearing, the Veteran and representative contended generally that the right eye disability had worsened since the July 2016 VA examination. See February 2017 Board hearing transcript at 21-22 ("from the exam in 2016, he feels that that condition, from then until now, has also increased in severity"). The Board finds that the VA examination reports, in connection with the other evidence of record (including the Veteran's report of current symptomology at the February 2017 Board hearing as well as documented in a September 2016 private treatment record - dated after the most recent VA examination), accurately reflects the eye symptoms and level of impairment throughout the initial rating period (including any additional "worsening" since the July 2016 VA examination). The Veteran has not reported - either at the February 2017 Board hearing or at any point since the July 2016 VA examination - any additional visual impairment or incapacitating episodes associated with the right eye macular pucker that would serve as the basis for a disability rating in excess of 10 percent. As such, the Board finds that additional VA examination is not required, and the Board may render a decision based on the evidence of record. The Veteran and his spouse testified at a hearing before the Board in February 2017 before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Veterans Law Judge, in pertinent part, took testimony with respect to the issue of higher initial ratings for right eye macular pucker. (The Veterans Law Judge also took testimony with respect to service connection for right and left hand paresthesia and numbness granted herein.) In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the Board hearing, the Veterans Law Judge advised the Veteran as to the issues on appeal. With respect to the initial rating for right eye macular pucker on appeal decided herein, the Veteran's Law Judge specifically asked and the Veteran testified regarding symptoms, limitations, and problems associated with the right eye disability, including diminished visual acuity. As the Veteran and his spouse presented evidence of symptoms and functional impairments due to the right eye macular pucker, and there is additionally medical evidence reflecting clinical measures and assessments of the severity of the right eye disability, there is both lay and medical evidence reflecting on the degree of disability; therefore, there is no overlooked, missing, or outstanding evidence as to this rating issue. Moreover, neither the Veteran nor the representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and the Board can adjudicate the issues based on the current record. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection for Right and Left Hand Paresthesia/Neuropathy Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2017). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In this case, the Board finds that the weight of the evidence is against a finding that the Veteran has current diagnosed disabilities associated with the right and left hand symptoms of numbness and paresthesia, which are not "chronic diseases" under 38 C.F.R. § 3.309(a) (2017). As such, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service (38 C.F.R. § 3.303(b)) or manifesting within one year of service separation (38 C.F.R. § 3.307 (2017)) do not apply. Service connection may also be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective signs of illness. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). Service personnel and treatment records reflect that the Veteran was deployed to Kuwait in Southwest Asia in 2008; therefore, the Veteran in this case is a "Persian Gulf veteran" as defined by 38 C.F.R. § 3.317. A "qualifying chronic disability" for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317(b). The Veteran contends that the bilateral hand neuropathy was caused by immunizations administered during service, specifically anthrax vaccinations administered in 2008 prior to deployment to Kuwait. See February 2017 Board hearing transcript at 3, 15-16. The Veteran testified that symptoms of neuropathy and paresthesia began in 2008 or 2009 (during service). See id. at 3-4, 13. The Veteran contends that he discussed symptoms of paresthesia and numbness with a staff neurologist during service. See e.g., November 2012 notice of disagreement, January 2014 written statement. As noted above, the Veteran had service in the Southwest Asia Theater of operations during the Persian Gulf War. As pertinent here, a "qualifying chronic disability" for VA purposes is a chronic disability resulting from an undiagnosed illness. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(A). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, neurological signs or symptoms. 38 C.F.R. § 3.317(b). Nexus evidence is not required. Gutierrez, 19 Vet. App. at 10. At a September 2010 VA examination, the Veteran reported episodic symptoms of pain, weakness, and decreased grip strength in both hands for one year and that it was periodically difficult to grip or hold items. The September 2010 VA examination report notes that, upon neurologic examination of the upper extremities, motor and sensory testing was normal and deep tendon reflexes were +2 at the biceps, triceps, and brachioradialis, bilaterally. Negative Tinel's sign, Phalen's test, and ulnar Tinel's sign were noted. The VA examination report notes a normal peripheral nerve examination and no finding of peripheral nerve disease. A March 2017 private treatment record notes that the Veteran reported neuropathy in both hands with numbness and tingling symptomatology since 2008 following in-service anthrax injections. A "diagnosis" of bilateral carpal tunnel syndrome was rendered. The private treatment record notes that there was a question as to whether neuropathy or bilateral carpal tunnel syndrome was the cause of the reported pain and numbness symptoms and an EMG of both upper extremities were ordered. A March 2017 private EMG and nerve conduction study report notes electro-physiological evidence of a mild acute nerve impingement at the left C7-8 root level consistent with cervical radiculopathy. No evidence of peripheral or entrapment neuropathy was noted. The report notes that an EMG may miss a small fiber neuropathy related to the Veteran's previous anthrax injection. While the March 2017 private treatment records purport to render a "diagnosis" of bilateral carpal tunnel syndrome, the June 2017 VHA examiner indicated that, while the findings were suggestive of a possible diagnosis of bilateral carpal tunnel syndrome, the EMG/NCV that was subsequently performed did not confirm the diagnosis. The VHA examiner noted that EMG/NCV is the diagnostic test of choice to make a diagnosis of carpal tunnel syndrome and a negative study essentially excludes this diagnosis. The March 2017 study also did not show any evidence of carpal tunnel syndrome, any other peripheral nerve entrapment, or peripheral neuropathy. The VHA examiner noted that the March 2017 EMG showed fibrillation potentials in the left extensor digitorum communis muscle that "could suggest" either a left C6, C7, C8 radiculopathy or left radial neuropathy, but the study did not provide sufficient electrodiagnostic information to distinguish between these two possibilities. The June 2017 VHA examiner indicated that, if the Veteran has or had a peripheral nerve entrapment, such as carpal tunnel syndrome, peripheral neuropathy, or radiculopathy of any etiology, it would have to be confirmed on clinical examination or EMG/NCV - which has not happened in this case. The VHA examiner further noted that, while a normal EMG/NCV does not exclude a small fiber neuropathy, the neurological examination would show some abnormalities or sensory or reflex examinations to suggest said diagnosis. The VHA examiner opined that, given the normal neurological examinations performed in March 2017 and September 2010, there is no clinical evidence that the Veteran has or had a small fiber neuropathy. In Joyner v. McDonald, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) overruled the Court in its holding that pain alone was not a disability even as an undiagnosed illness. 766 F.3d 1393, 1395 (Fed. Cir. 2014). The Federal Circuit specifically noted that the plain language of 38 U.S.C. § 1117 makes clear that pain, such as muscle pain or joint pain, may establish an undiagnosed illness that causes a qualifying chronic disability. Id. By logical extension, the same is also true for neurological signs and symptoms. As detailed above, throughout the course of this appeal and to health care professionals, the Veteran has consistently reported bilateral hand numbness and paresthesia. The Veteran is competent to report any symptoms that come to him through the senses including numbness and tingling in the extremities. Further, the evidence reflects symptoms of bilateral hand numbness and paresthesia consistent with a compensable disability rating. The Board finds these symptoms are most closely analogous to impairment of the median nerve under 38 C.F.R. § 4.124a (2017), Diagnostic Code 8515, which provides a 10 percent rating for mild incomplete paralysis of the median nerve. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2017). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 4.2, 4.6 (2017). As discussed above, the Veteran has reported ongoing numbness and paresthesia in both hands throughout the appeal period. The Board finds that the Veteran's subjective reports of numbness and paresthesia and associated sensory involvement more closely approximates mild incomplete paralysis of the median nerve. The Board finds that the criteria for 10 percent disability ratings for each extremity rated by analogy to Diagnostic Code 8515 are supported by the evidence in this case. For these reasons, and resolving reasonable doubt in the Veteran's favor, presumptive service connection for undiagnosed right and left hand numbness and paresthesia, as due to a qualifying chronic disability, is warranted. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The grant of presumptive service connection as due to a qualifying chronic disability renders moot all other theories of service connection. As such, the Board need not address the contention that the claimed symptoms are related to the in-service anthrax vaccinations (i.e., the theory of direct service connection under 38 C.F.R. § 3.303(d)). Initial Ratings for Right Eye Macular Pucker Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4 (2017). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2017). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2017). Where there is a question as to which of two disability ratings shall be applied, the higher rating is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where, as in this case, the question for consideration is the propriety of the initial ratings assigned, evaluation of the all evidence and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has considered, and found inappropriate, the assignment of staged ratings for any part of the initial rating period on appeal. The Veteran is in receipt of a noncompensable disability rating for the period from October 1, 2010 to July 13, 2016, and a 10 percent rating from July 13, 2016, for the right eye macular pucker under 38 C.F.R. § 4.79, Diagnostic Code 6006-6066 (maculopathy rated under visual impairment). Eye disabilities are rated under Diagnostic Codes 6000 to 6099. Under General Rating Formula for Diagnostic Codes 6000 through 6009, eye disorders are rated on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher rating. With respect to incapacitating episodes: a 10 percent rating is warranted where the condition results in incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the past 12 months. A 20 percent rating is warranted where the condition results in incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months. A 40 percent rating is warranted where the condition results in incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A 60 percent rating is warranted where the condition results in incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.79. Alternatively, these eye disorders are rated based on visual impairment. The regulations direct that evaluation of visual impairment is to be rated based on the consideration of three factors: (1) impairment of visual acuity (excluding developmental errors of refraction), (2) visual field, and (3) muscle function. 38 C.F.R. § 4.75. Under the criteria for rating visual acuity outlined in Diagnostic Codes 6061 to 6066, the evaluation of visual impairment should be based on central visual acuity on the basis of corrected distance vision with central fixation, even if a central scotoma is present. 38 C.F.R. § 4.76(b). However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, evaluate the visual acuity of the poorer eye using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. 38 C.F.R. § 4.76 directs that an examination of visual acuity must include the central uncorrected and corrected visual acuity for distance and near vision using Snellen's test type or its equivalent. To warrant a 10 percent rating based on impairment of central visual acuity, the vision in one eye must be at least 20/50. Vision in both eyes of 20/40 or better is commensurate with a noncompensable disability rating. 38 C.F.R. § 4.79, Diagnostic Codes 6061-6066. With respect to rating based on impairment of visual field, 38 C.F.R. § 4.76a explains that the normal visual field extent at eight principal meridians is (expressed in degrees): Temporally: 85, Down temporally: 85, Down: 65, Down nasally: 50, Nasally: 60, Up nasally: 55, Up: 45, Up temporally: 55. The combined sum is 500. To calculate the visual field, determine the average concentric contraction of the visual field of each eye by measuring the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart, adding them, and dividing the sum by eight. Id. The rating criteria dictate that when the remaining visual field is 46-60 degrees, a 10 percent rating is applied for unilateral impairment; alternatively, the affected eye may be evaluated as 20/50. When the remaining visual field is 31-45 degrees, a 10 percent rating is applied for unilateral impairment; or alternatively the affected eye may be evaluated as 20/70. When the remaining visual field is 16-30 degrees, a 10 percent rating is applied for unilateral impairment; or alternatively the affected eye may be evaluated as 20/100. 38 C.F.R. § 4.79. With respect to rating for impairment of muscle function, Diagnostic Code 6090 directs that the degree of diplopia be evaluated by an equivalent visual acuity. Diagnostic Code 6091 directs that symblepharaon be evaluated based on visual impairment, lagophthalmos (Diagnostic Code 6022), disfigurement (Diagnostic Code 7800), etc. on the particular findings. Id. Examinations of visual fields will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. 38 C.F.R. § 4.75(b). Throughout the course of the appeal, the Veteran has contended that the service-connected right eye disability has been manifested by more severe symptoms or impairment than that completed by the noncompensable and 10 percent "staged" ratings assigned. See generally November 2012 notice of disagreement (requesting a combined disability rating of 50 percent in connection with a higher rating for right eye macular pucker). In a January 2014 written statement, the Veteran contended that the vision in the right eye was progressively worsening. In a February 2017 written statement, the Veteran contended that the disability rating for the right eye macular pucker should be re-evaluated based on a September 2016 private eye evaluation report. At the February 2017 Board hearing, the Veteran testified that he was diagnosed with right eye macular pucker during service in 2006 following symptoms of blurred vision. The Veteran testified that this led to decreased right eye visual acuity as well as poor night vision and decreased depth perception. The Veteran contended that the severity of the eye disability was basically the same from 2010 (when service connection was established) to 2016 (when the 10 percent disability rating was assigned). See Board hearing transcript at 16-18. The Veteran's spouse testified that she was aware of the Veteran's diminished night vision and had witnessed increases in vision impairment since he returned from deployment. The spouse testified that she has to drive at night to the extent possible, and that the Veteran had increased difficulty with reading. See id. at 23. An April 2006 service treatment record notes that the Veteran was diagnosed with right eye macular puckering and referred for further evaluation. August and September 2006 service treatment records note right eye vision measured at 20/50 (left eye vision measured at 20/25 and 20/20). A December 2007 service treatment record notes right eye vision measured at 20/50. A May 2009 service treatment record notes corrected distance vision measured at 20/40 with a macular defect. At the September 2010 VA examination, the Veteran reported distorted vision, sensitivity to light, and blurred vision associated with the right eye macular pucker. Upon examination, corrected distance vision on the right was measured at 20/40. In comparing the near and distance corrected vision, no difference equal to two or more scheduled steps or lines of visual acuity was noted. The lens required to correct distance vision in the poorer eye did not differ by more than three diopters from the lens required to correct distance vision in the better eye. Macular pucker was noted upon examination of the right eye. At the July 2016 VA examination, the Veteran reported worsening symptoms of blurriness in the right eye. Corrected distance acuity in the right eye was measured at 20/70. Corrected near acuity in the right eye was measured at 20/50. The VA examination report notes that the Veteran did not have a difference equal to two or more lines on the Snellen test type chart between distance and near corrected vision. Pupils were equal, round, and reactive to light without an afferent pupillary defect. A macular pucker was noted upon internal eye exam. The VA examiner noted that the Veteran had a visual field defect that did not result in contraction or loss of visual field. (Non-service-connected) preoperative cataracts were noted bilaterally. The examination report notes no incapacitating episodes attributable to any eye disorder in the previous 12 months. A September 2016 private treatment record notes that the Veteran reported distortion of vision in the right eye for the previous 10 years effecting central vision that was of moderate severity. An assessment of right eye epirential membrane (macular pucker) as well as posterior vitreous detachment in both eyes, right eye nuclear sclerosis, and right eye senile cataract was rendered. After a review of all the evidence, lay and medical, the Board finds that the Veteran's right eye macular pucker has been manifested by corrected distance vision of 20/70 in the right eye, distorted and blurred vision, and sensitivity to light, which more nearly approximates the criteria for a 10 percent disability rating under Diagnostic Code 6006-6066 for the entire rating period from October 1, 2010. 38 C.F.R. §§ 4.3, 4.7. Service connection has not been established for any left eye disorder; therefore, visual acuity of 20/40 or better is assigned for purposes of determining whether a higher disability rating is warranted based on diminished visual acuity in the service-connected right eye. As detailed above, the service treatment records dated proximate in time to when the Veteran filed the service connection claim for a right eye disability note corrected distance vision in the right eye measured at 20/50. See August and September 2006, December 2007 service treatment records. Further, the July 2016 VA examination report notes corrected distance vision in the right eye measured at 20/70. Under Diagnostic Code 6066, a 10 percent disability rating is assigned for vision in one eye of 20/50 or 20/70 with vision in the other eye of 20/40. See 38 C.F.R. § 4.79. As such, the Board finds that an initial disability rating of 10 percent for the right eye macular pucker based on diminished visual acuity is warranted for the entire initial rating period from October 1, 2010. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that the weight of the evidence demonstrates that the criteria for a disability rating in excess of 10 percent have not been met or more nearly approximated for any part of the initial rating period. The Board finds that the weight of the evidence is against a finding that the right eye macular puckering has been manifested by diminished vision in one eye of greater than 20/70. 38 C.F.R. §§ 4.3, 4.7. Because service connection has not been established for a left eye disorder, visual acuity of 20/40 or better is assigned to the left eye for purposes of determining whether a higher disability rating is warranted based on diminished visual acuity in the right eye. In order to warrant a disability rating in excess of 10 percent (i.e., 20 percent) based on diminished visual acuity in one eye (with the non-service-connected eye assessed as visual acuity of 20/40), vision in the service-connected eye must be at least 20/200, which has not been demonstrated in this case. VA examined the eyes in September 2010 and July 2016, and on both occasions the Veteran demonstrated corrected distance vision of 20/70 or better in the right eye. The Veteran does not have a difference equal to two or more lines on the Snellen's test type chart or its equivalent between distance and near corrected vision, with the near vision being worse. The evidence of record does not reflect that the corrected distance in the right eye has been worse than 20/70 during any part of the initial rating period, nor has the Veteran alleged otherwise. Next, the Board finds that the weight of the evidence is against finding that the right eye macular puckering has been manifested by incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months of the entire rating period, as required for disability rating in excess of 10 percent. 38 C.F.R. § 4.79. The September 2010 and July 2016 VA examination reports indicate that the Veteran has not had any incapacitating episodes attributable to any eye disorder during the previous 12 months. VA and private treatment records do not reveal any incapacitating episodes attributable to any eye disorder over any 12-month period. Nor has the Veteran reported any incapacitating episodes attributable to the eye disorder. Additionally, in this case, the July 2016 VA examiner indicated that the Veteran had a visual field defect (or a condition that may result in a visual field defect). The July 2016 VA examiner also indicated that the Veteran had neither loss of visual field nor contraction of visual field. The September 2010 VA examination report notes that Goldmann visual field was normal in the right eye. As such, the Board finds that the weight of the evidence is against a finding that the right eye macular puckering has been manifested by visual field impairment. Id. Finally, the Board has considered whether a rating is warranted for impairment of muscle function under Diagnostic Codes 6090 (diplopia) or 6091 (symblepharon). The September 2010 and July 2016 VA examiner specifically found that diplopia was not present in the right eye. VA and private treatment records do not indicate diplopia or symblepharon in the right eye, and the Veteran has neither testified nor submitted statements to support such a finding. Accordingly, the Board finds that a higher disability rating for right eye macular puckering is not warranted based on impairment of muscle function. Id. Extraschedular Referral Considerations The Board has considered whether referral for an extraschedular rating is warranted for the right eye macular pucker for any part of the initial rating period. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2017). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate; therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular rating is, therefore, adequate, and no referral is required. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). In the second step of the inquiry, however, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the right eye macular pucker is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The right eye macular pucker has been manifested by corrected distance vision of 20/70 in the right eye, distorted and blurred vision, and sensitivity to light, with no incapacitating episodes, abnormalities in muscle function, or contraction or loss of visual field. The schedular rating criteria provide for ratings based on visual acuity and incapacitating episodes. The Veteran's complaints concern diminished visual acuity, which are the foundation of the schedular rating criteria. The VA examination reports and private treatment records documented visual acuity, other eye abnormalities (addressed in the rating schedule), and symptoms. Visual impairment, measured by impairment of visual acuity and impairment of visual fields, is explicitly part of the schedular rating criteria. The rating schedular also contemplates rating based on incapacitating issues. In this case, comparing the disability level and symptomatology of the right eye macular pucker to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule; therefore, the schedular rating criteria are adequate to rate the service-connected eye disability. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the right eye macular pucker, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part of a rating claim when unemployability is expressly raised by a veteran or reasonably raised by the record during the rating appeal. At the February 2017 Board hearing, the Veteran reported that he was working as a doctor. The Veteran has not contended that he is unemployed because of service-connected disabilities, and the other evidence of record does not so suggest; thus, the Board finds that Rice is inapplicable in this case because neither the Veteran nor the evidence suggests unemployability due to the service-connected disabilities. ORDER Service connection for undiagnosed right hand numbness and paresthesia as due to a qualifying chronic disability is granted. Service connection for undiagnosed left hand numbness and paresthesia as due to a qualifying chronic disability is granted. An initial disability rating for right eye macular pucker of 10 percent, but no higher, for the period from October 1, 2010 to July 13, 2016, is granted; a disability rating in excess of 10 percent, for the entire rating period from October 1, 2010, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs