Citation Nr: 18140647 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 12-25 184 DATE: October 3, 2018 ORDER Service connection for a right eye disability, to include as secondary to the service-connected headache disability and/or as secondary to the service-connected traumatic brain injury (TBI), is denied. FINDINGS OF FACT 1. The weight of the competent and credible evidence, both lay and medical, indicate that the Veteran’s right eye disability is not causally or etiologically related to service, and is not secondary to his service-connected headaches and/or TBI. 2. The Veteran’s refractive errors, to include hyperopia, presbyopia, and astigmatism, do not constitute a disease or injury for VA compensation purposes. CONCLUSION OF LAW The criteria to establish service connection for a right eye disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017).   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1976 to April 1978. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a May 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, this matter previously was before the Board in January 2015, February 2016, and May 2017. During the pendency of the appeal, the Veteran’s claims for service connection for a left eye disability and a right knee disability were granted. See December 2015 and October 2017 rating decisions (of which the Veteran was notified in February 2018). The Board finds that there has been substantial compliance with the previous Board remand directives. The Veteran waived a hearing before the Board in his September 2012 substantive appeal, via a VA Form 9. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran or his representative and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Pertinent Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2017). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Right Eye Disability The Veteran has several different theories of entitlement for service connection as to the right eye disabilities. First, he contends that his right eye disabilities had onset during or were otherwise related to active service. Specifically, he reports that he was sandblasting paint off the side of the USS Saratoga in preparation for repainting the ship, when “paint chippings stuck to [his] pupils...” The Veteran reported seeking treatment at sick call and was given pain medication. See September 2012 VA Form 9. Second, the Veteran asserts his right eye disabilities were causally related to or aggravated by the two head injuries sustained during service, which are currently service-connected as a traumatic brain injury (TBI). Finally, the Veteran contends that his right eye disabilities were causally related to or aggravated by the service-connected migraine headache disability. The Veteran has been diagnosed with the following right eye disabilities during the appellate period: blepharitis, pinguecula, cataracts, purulent endophthalmitis, chorioretinal scar, nuclear sclerosis, a retinal hole, astigmatism, refractive error, dry eye, pre-glaucoma, and primary open angle glaucoma. The Veteran has also been diagnosed with photophobia and scotoma during the appellate period in a March 2013 VA examination and a February 2017 private disability benefit questionnaire (DBQ), received by VA in March 2017. After a careful review of all the evidence of record, both lay and medical, the Board finds that the evidence is against a finding that the Veteran’s right eye disabilities are related to service or his service-connected migraine headache and/or TBI disabilities. Turning to the evidence, the Veteran’s July 1975 Report of Medical History at enlistment reported a history of “eye trouble.” The specific past eye trouble was clarified to indicate he previously wore glasses. The corresponding examination report at entrance notes a refractive error, and measured the Veteran’s distant vision as 20/20 in the right eye and 20/30 in the left eye. The clinical eye examination at entrance was normal. A service treatment record dated in June 1976 shows that the Veteran’s vision was 20/25 in the right eye. Other than the refractive errors noted above, the Veteran’s service treatment records are completely silent as to any complaints, treatment, or diagnoses of a right eye disability during service. The Veteran’s April 1978 examination report at discharge shows a refractive error which was measured at 20/20 for the right eye and 20/25 for the left eye for distant vision. The examination report at discharge did not note an abnormal clinical eye examination. A post-service VA medical treatment record dated in September 2005 shows that the Veteran denied eye pain, but complained of seeing occasional flashes with migraines. Subsequent treatment records, dated in February 2009, indicate that the Veteran never had an ocular implant or orbital eye prosthesis. At the time, it was noted that the Veteran’s previous employment was as a metal worker. The Veteran answered “yes” to whether he ever wore protective eye coverings and “no” to whether he ever had metal in his eye or had injury to the eye by a metallic object. During the same time, the Veteran reported that he had constant headaches, which he attributed to his eye problems. The medical professional noted that the Veteran had diagnoses of lattice retinal degeneration, nuclear sclerosis, and a retinal hole. Additional VA treatment records dated in August 2011 and February 2012 indicate that the Veteran denied blurred vision, double vision, or disturbed vision. On physical examination of the eyes, the medical professional noted the Veteran’s conjunctiva, cornea, and sclera were normal with no icterus. The Veteran further denied having trouble seeing in one or both eyes. In February 2011, a psychology consult note indicated that other health issues, included status-post laser surgery on the right eye, were pending further evaluation. During an August 2013 VA examination for his migraine headaches, it was noted that the Veteran had changes in vision such as scotoma and photophobia. In April 2015, the Veteran underwent a VA eye examination, at which time, the examiner rendered diagnoses of right eye blepharitis, presbyopia, peripheral retinal scar, and, hyperopia. The Veteran recalled getting paint chips in his eyes while sandblasting paint off a ship during service and reported that the pain chips were removed without complication. He further reported sensitivity to light during migraines. The same examiner opined that the Veteran’s headaches with the symptom of visual aura were secondary to his service-connected TBI. A positive opinion was rendered also in regard to the Veteran’s left eye glaucoma. The examiner further opined that the migraines with visual aura and increased cupping were not a result of the paint chips that were stuck in his eyes during service. Lastly, the examiner noted that there was no indication in the treatment records that the Veteran’s bilateral eye disabilities were the result of paint chips in his eyes. Subsequent VA treatment records dated in January 2016 indicate the Veteran had a family history of glaucoma. Additionally, the VA optometry resident physician, reported the Veteran had retinal holes in both eyes, which were status post laser retinopexy. The Veteran underwent an additional VA-contracted eye examination in February 2016. The examiner, an optometrist, did not review the claims file or the Veteran’s treatment records. After physical examination, the VA examiner diagnosed the Veteran with nuclear sclerosis, pinguecula, lattice degeneration, conjunctival nevus, and an arcus cornea of the right eye. The Veteran’s uncorrected near and distant vision were 20/40 or better and the Veteran’s corrected near and distant vision was 20/40 or better. The Veteran had an arcus cornea of the right eye. The VA=contracted examiner only provided an etiology opinion as to a left eye disability and did not provide an etiology opinion as to the right eye disabilities. VA treatment records dated March 2016 said the Veteran reported having dry eyes, which he attributed to working in the desert. A March 2016 VA treatment record diagnosed the Veteran with lattice degeneration, retinal holes, mild cataracts of both eyes, and dry eye syndrome. No etiology opinion was provided for these conditions. A July 2016 addendum opinion from an attending physician was obtained. The physician listed each diagnosis rendered in the April 2015 VA examination and the February 2016 VA-contracted examination. Then he defined each condition and noted the etiology of each condition, if known. The examiner concluded it was less likely than not that any of the Veteran’s diagnosed right eye conditions were related to paint chips in his eyes and/or head trauma. In support of his conclusion, the examiner noted that none of the conditions diagnosed in the April 2015 or February 2016 examination reports were conditions that result from trauma, a foreign body in the eye, and/or chemical exposure. The examiner noted that all of the diagnosed conditions of the right eye were either age-related or idiopathic with no known identifiable cause. The examiner reported that there was no pathophysiologic mechanism to link any of the conditions to paint chip exposure and/or the type of trauma caused by a foreign body in the eye. Additionally, no pathophysiological link between the Veteran’s right eye diagnoses and a head trauma was found. Additionally, the examiner found that it was less likely than not that any of the Veteran’s eye conditions were proximately caused by or aggravated by the service-connected migraine headache disability because there was no plausible etiology by which episodic neurovascular headaches could cause any of the diagnosed eye conditions based on the known etiologies and pathophysiologies of those conditions. The Veteran underwent another VA-contracted examination in August 2016. The examiner, an optometrist, reviewed the Veteran’s electronic claims file and peer reviewed medical literature. The examiner diagnosed the Veteran with blepharitis, pinguecula, a cataract, purulent endophthalmitis, chorioretinal scars, and pre-glaucoma of the right eye. The Veteran reported to the examiner that he had chorioretinal scars since 1977 when paint chips flew into his eyes. He also reported he sustained two head injuries during service. The Veteran was not experiencing eye pain or other symptoms during the examination. The examiner concluded the Veteran did not have a specific right eye disorder; however, the current eye conditions were at least as likely as not due to congenital factors. It was noted the Veteran did not have scotoma in either eye on examination. Further the examiner attributed the chorioretinal scars as a residual of the post-service laser procedure, and found that the scars were not due to trauma resulting from paint chips in his eyes. The examiner also noted that a current finding of purulent endophthalmitis was as likely as not secondary to the past intraocular surgery. The Veteran denied experiencing photophobia during this examination, and it wasn’t noted clinically. In support of the conclusions provided, the examiner noted the Veteran’s treatment records in 2012 and 2014 report the Veteran had a past head injury after running into an air conditioning duct on the ship during service; however, the examiner noted that the diagnoses of scotoma and photophobia were only rendered after the Veteran underwent post-service laser eye surgery. Additionally, the examiner noted the service treatment records were silent as to symptoms, diagnoses, or treatment for any injury resulting from paint chips in his eyes during service. Thus, based on the above, the examiner concluded it was less likely than not that the current right eye conditions were related to any injury or incident during service. VA neurology and neuromuscular treatment records in November 2016 report the Veteran had migraine headaches with photophobia. The clinical examination of the eyes was negative. A February 2017 DBQ for headaches and migraines was submitted in March 2017. The physician who completed the DBQ worked at a VA hospital. The physician noted that the Veteran experienced headaches as intense, sharp pain associated with scotoma and photophobia. No etiology opinion was provided for the right eye disabilities. In June 2017, a VA-contracted optometrist reviewed the Veteran’s claims file and acknowledged diagnoses of blepharitis, presbyopia, peripheral retinal scar, and hyperopia of the right eye, as well as a regular astigmatism. The examiner noted that the Veteran sustained two head injuries during service that resulted in service connected migraine headaches with a visual aura approximately 19 years earlier. The examiner noted the Veteran’s recollection of having paint chips in his eyes from sandblasting a ship during service, his report that the paint chips were removed without complication, and that he Veteran was unaware of any residual injury to his eyes. After reviewing the Veteran’s claims file, the examiner concluded that the Veteran’s right eye disabilities were less likely than not related to the paint chips in his eyes during service, the in-service head injuries and the service-connected TBI and headache disabilities. In support of this opinion, the examiner determined the chorioretinal scars were secondary to post-service laser surgery, and not due to past trauma from paint chips in the eyes. Of note, the examiner considered the Veteran’s statement that he had had the scars since 1977 but emphasized that the scars were the result of laser surgery and not the result of past trauma or injury from paint chips. Moreover, the examiner determined that the Veteran’s purulent endophthalmitis of the right eye with associated blepharitis to be not related to in-service eye trauma, but rather due to previous intraocular surgery. The examiner also opined that the Veteran’s cataracts, pinguecula, hyperopia and presbyopia were at least as likely as not due to other factors, such as aging, sun exposure, and a 30-year smoking history, and not due to an injury from paint chips in his eyes. The Veteran had a previous retinal detachment in the right eye, which was treated with a retinopexy. The examiner determined that the Veteran did not have evidence of scotoma. The examiner concluded that current medical evidence did not support the Veteran’s contentions that his right eye disabilities were caused or aggravated by the Veteran’s service-connected headaches. The Board further notes that the Veteran’s hyperopia, presbyopia, and astigmatism are, by definition, types of refractive errors. VA regulations provide that refractive error does not constitute a “disease” or “injury” in the meaning of applicable legislation for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9 (2017). Therefore, service connection may not be allowed for refractive error of the eyes. See VAOPGCPREC 82-90 (July 18, 1990). As such, the Board finds that the Veteran’s refractive errors do not constitute a disease or injury for VA compensation purposes and there is no evidence of a superimposed disease or injury during service. As to the other right eye disabilities of record, the Board finds that the weight of the evidence, particularly to include the probative June 2017 VA opinion, is against a finding that the Veteran’s variously diagnosed right eye disorders are etiologically related to service, including due the paint chips that were stuck to the Veteran’s eyes. In addition, the weight of the evidence indicates that the right eye disabilities were not proximately due to, or aggravated by, the service-connected disabilities. The Veteran has not submitted a medical evidence in support of his claim. The only evidence in support of the claim is the lay evidence provided by the Veteran. The Board recognizes that lay persons are competent to attest to factual matters of which they have first-hand knowledge; however, lay persons generally do not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of his eye disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Eye disorders are medically complex disease processes because of their multiple possible etiologies requires specialized testing to diagnose, and manifest symptomatology that may overlap with other disorders. Thus, insomuch as the Veteran has attempted to establish through his own lay assertions a nexus between his current right eye disorders and either an injury in service or his service-connected disabilities, he is not competent to provide such an etiology opinion due to the medical complexity of the matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, as the Veteran has not demonstrated that he has the requisite training and knowledge, the Veteran is not competent to render an opinion as to etiology of the right eye disabilities. In summary, the Board finds that the competent, credible, and probative evidence of record weighs against the claim for service connection for the right eye disabilities. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Finally, the Board notes that neither the Veteran nor his representative raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Harper, Tristin