Citation Nr: 18139868 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 17-43 028 DATE: October 1, 2018 ORDER An initial rating of 100 percent since October 7, 2003, for ulcerative colitis and residuals of J pouch surgery is granted. Service connection for left eye uveitis, uveitic glaucoma with Ahmed valve placement, and cataracts is granted. Service connection for right eye uveitis, uveitic glaucoma with Ahmed valve placement, cataracts, and residuals of a globe puncture injury is granted. FINDINGS OF FACT 1. Since October 7, 2003, the Veteran’s ulcerative colitis and residuals of J pouch surgery have resulted in pronounced disability with serious complications. 2. The Veteran’s ulcerative colitis and residuals of J pouch surgery caused left eye uveitis, uveitic glaucoma with Ahmed valve placement, and cataracts. 3. The Veteran’s ulcerative colitis and residuals of J pouch surgery caused right eye uveitis, uveitic glaucoma with Ahmed valve placement, and cataracts, and resulted in a globe puncture injury. CONCLUSIONS OF LAW 1. The criteria for a rating of 100 percent, since October 7, 2003, for ulcerative colitis and residuals of J pouch surgery have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.118, Diagnostic Code 7804; Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (Aug. 13, 2018) (to be codified at 38 C.F.R. § 4.118, Diagnostic Code 7801). 2. The criteria for service connection for left eye uveitis, uveitic glaucoma with Ahmed valve placement, and cataracts have been met. 38 U.S.C. §§ 1131, 1137, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.326(a) (2017). 3. The criteria for service connection for right eye uveitis, uveitic glaucoma with Ahmed valve placement, cataracts, and residuals of a globe puncture injury have been met. 38 U.S.C. §§ 1131, 1137, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.326(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from December 1959 to February 1962. 1. Entitlement to an initial rating of more than 30 percent since October 7, 2003, for ulcerative colitis and residuals of J pouch surgery. Disability evaluations are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). The Veteran’s gastrointestinal disorders are rated according to 38 C.F.R. § 4.114, Diagnostic Code 7323, for ulcerative colitis. A 100 percent rating is warranted for pronounced disease resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess. 38 C.F.R. § 4.114, Diagnostic Code 7323 (2017). Diagnostic code 7801 states that a scar not involving the head, face, or neck that is associated with underlying soft tissue damage warrants a rating at 10 percent if the area of the scar is at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square meters). Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (Aug. 13, 2018) (to be codified at 38 C.F.R. § 4.118, Diagnostic Code 7801). Scars that are unstable or painful are rated according to diagnostic code 7804. Diagnostic code 7804 states that one or two scars that are unstable or painful warrants a 10 percent evaluation. Note (1) to the diagnostic code states that “An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” Note (2) states that “If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.” Note (3) states: “Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable.” 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In October 2003, the Veteran underwent surgery and was given a discharge diagnosis of ulcerative colitis status-post total proctolectomy with ileal J pouch and loop ileostomy. In 2006 and 2007, he underwent several more procedures, including several scopes; an ileostomy enema; and completion of rectal mucosectomy, exploratory laparotomy, extensive lysis of adhesions, takedown of ioleorectal J pouch, and formation of a new J pouch with ileoanal anastomosis. In October 2007, he again underwent surgery and was given a discharge diagnosis of ulcerative colitis, status-post ileoanal pouch reconstruction. Since his initial surgery in October 2003, VA and private treatment records indicate that the Veteran has had chronic pain in the rectal area and in the pouch; peri rectal burning and irritation; fecal incontinence; frequent bowel movements, up to as many as 20 to 22 per day; diarrhea; had a residual distal rectum; required dilatation of the rectum up to 4 times per day; required regular use of several medications, including pain medications, anti diarrheal medications, and antibiotics; and had narrowing at the anorectal mucosa, anal stenosis, small bowel obstruction,; erythema, ulcers, and pouchitis. In an April 2016 statement, the Veteran summarized his symptoms saying that he had to wear adult diapers at night to prevent bowel accidents, had to sit near bathrooms when in public, had several intestinal blockages due to scar tissue which resulted in his stomach needing to be pumped, and that his pouch would get infected and he would have to take antibiotics. An October 2016 VA treatment record states that the Veteran had been taking antibiotics “for the last 2-3 years almost regularly.” In December 2016, the Veteran was afforded VA examinations. The examiner noted that the Veteran took medications and had bouts of pouchitis which required antibiotics. The examiner indicated that the Veteran had 4 exacerbations or attacks of pouchitis in the prior 12 months. The Veteran reported loose stools and that he had bowel movements approximately every 2 hours. He did not have weight loss or malnutrition. He had a surgical scar measuring 28 centimeters by 0.5 centimeters on his anterior abdominal wall. The examiner indicated that the scar was not painful or unstable. The Board finds that the Veteran’s ulcerative colitis and residuals of his J pouch surgery have resulted in pronounced disability with serious complications and, therefore, most closely approximate a 100 percent rating. 38 C.F.R. § 4.7. A separate rating for the Veteran’s surgical scar is not warranted as the scar does not meet the minimum criteria for a compensable rating. See 38 C.F.R. § 4.118, Diagnostic Code 7804; Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (Aug. 13, 2018) (to be codified at 38 C.F.R. § 4.118, Diagnostic Code 7801). 2. Entitlement to service connection for right and left eye disorders. Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 where it is demonstrated that a service-connected disorder has caused or aggravated a nonservice connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). VA treatment records indicate that the Veteran’s gastrointestinal disorders, including his ulcerative colitis and pouchitis, caused bilateral uveitis and uveitic glaucoma. In April 2011, Ahmed valves were placed in each eye for treatment of the glaucoma. A June 2010 VA treatment record states that the Veteran had moderate cataracts that were likely worsened by chronic topical prednisone therapy for uveitis. A June 2012 VA treatment record indicates that the Veteran had posterior subscapular (PSC) cataracts. VA treatment records indicate that in March 2012, the Veteran underwent surgery for right eye cataract extraction. Afterward, he had vitreous hemorrhaging and, nine days later, underwent another surgery. The post-operative diagnosis from the second surgery was hemorrhagic retinal detachment partially involving the macula, vitreous hemorrhage, retina tears, and choroidal detachment of the right eye. A November 2013 VA treatment record states that the Veteran had right eye blindness due to a history of a traumatic procedure. A July 2015 VA treatment record indicates that the Veteran had only hand motion vision in the right eye. An April 2016 VA medical opinion summarized VA post-operative treatment records stating that, during the first surgery, the Veteran had a peribulbar block which resulted in perforation of the eye, which subsequently led to retinal detachment, a loss of vision, and permanent silicone oil in the eye and, eventually, permanent loss of vision. The clinician stated that the Veteran’s “current vision is hand to motion and this [is] more than likely not a direct result of the perforation of the globe that happened during routine cataract surgery. . . . There is no question that the disability and the problems with the eye came because of the direct penetration of the needle into the eye during the peribulbar block.” The Board finds that the Veteran’s service-connected ulcerative colitis and pouchitis caused right and left eye uveitis, uveitic glaucoma with Ahmed valve placement, and cataracts. Therefore, service connection on a secondary basis is warranted. The Board also finds that any additional disability resulting from the right eye globe puncture injury, which occurred during treatment for the now service-connected right eye cataract, is also service connected. The Board notes that the Veteran had a claim pending for benefits under 38 C.F.R. § 1151 for residuals of the right eye globe puncture. The secondary service connection granted above is a greater benefit than the § 1151 benefit and, therefore, results in no harm to the Veteran. LAURA E. COLLINS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel