Citation Nr: 1805771 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 14-08 357 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for ocular surface disease (claimed as dry eyes). 2. Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder not otherwise specified (NOS), anxiety disorder, and alcoholism. 3. Entitlement to service connection for lumbosacral strain with 50 percent L1 compression. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Daniels, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1999 to November 2003. This case comes before the Board of Veterans' Appeals (Board) from a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Ocular Surface Disease The Veteran received a VA ophthalmology consultation in September 2010 and was diagnosed with ocular surface disease. As the Veteran's medical records establish a current diagnosis, and there is an indication, through assertions of the Veteran, that his ocular surface disease may be related to service, the Board finds that a medical examination with an opinion is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). Specifically, a remand is required to afford the Veteran a VA examination so as to determine the nature and etiology of his ocular surface disease. Lumbosacral Strain The Veteran received a VA general examination in October 2010 and was diagnosed with lumbosacral strain with 50 percent L1 compression. The examiner, however, did not provide an opinion with regard to the etiology of the Veteran's disability. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also 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."). Therefore, this claim must be remanded for a new examination. Acquired Psychiatric Disorder The Veteran received a VA examination in December 2010 and was diagnosed with a depressive disorder, but the examiner did not provide a nexus opinion. An addendum opinion was submitted in March 2013, and the examiner found that the depressive disorder criteria had not been met during service and, therefore, there was no evidence linking the disability to service. The Board notes that a medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). Therefore, this claim must be remanded for a new examination. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his ocular surface disease. The examiner should review the claims folder and note such review in the examination report. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's ocular surface disease had its onset or is otherwise related to the Veteran's military service. The examiner is asked to take into account the Veteran's experiences during services, including the treatment for diesel fuel in his eyes in April 2003, and getting a foreign object in his eye in October 2000 while changing a tire. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his lumbosacral strain with 50 percent L1 compression. The examiner should review the claims folder and note such review in the VA examination report. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's lumbosacral strain with 50 percent L1 compression had its onset or is otherwise related to the Veteran's military service. The examiner should specifically take into account the Veteran's lay statements, including his statements that he injured his back by pulling a fuel hose thousands of times per day during service. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his acquired psychiatric disorder, to include depressive disorder not otherwise specified (NOS), anxiety disorder, and alcoholism. The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or more) that any acquired psychiatric disorder had its onset in service or is otherwise the result of an incident in service. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 4. Following any additional indicated development, the AOJ should review the claims file and readjudicate the Veterans claims for service connection for ocular surface disease, lumbosacral strain with 50 percent L1 compression, and acquired psychiatric disorder, to include depressive disorder not otherwise specified (NOS), anxiety disorder, and alcoholism. If the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ Michael J. Skaltsounis Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).