Citation Nr: 18140981 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-46 365 DATE: October 9, 2018 REMANDED Entitlement to service connection for a right eye disability, to include as due to in-service herbicide exposure, and to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to service connection for hypertension (claimed as high blood pressure), to include due to in-service herbicide exposure, and to include as secondary to service-connected diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1959 to September 1981. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board notes that the Veteran is currently in receipt of a total disability rating based on individual unemployability (TDIU) and has been so since September 18, 2013. The Board believes it must cite this fact considering the number of claims raised at different times in this case. 1. Entitlement to service connection for a right eye disability, to include as due to in-service herbicide exposure, and to include as secondary to service-connected diabetes mellitus, type II. The Veteran contends that his diagnosed right eye disabilties are related to herbicide exposure in Vietnam. See February 2012 claim, August 2012 statement, September/November 2013 notices of disagreement, October 2015 memorandum from Veteran. It is presumed that the Veteran was exposed to herbicides, such as Agent Orange, during service in the Republic of Vietnam. Alternatively, he claims that his current right eye disabilities are related to his service-connectd diabetes mellitus, type II, or a possible in-service traumatic brain injury or exposion over his head. A June 2010 private opinion noted that “[w]hat is listed as an Agent Orange complication is retinopathy secondary to diabetes mellitus caused by Agent Orange.” The physician diagnosed the Veteran as having right eye optic neuropathy and cataracts (bilaterally). The physician then stated that a “definite etiology of the visual loss in the right right eye” could not be provided. Nevertheless, the physician indicated the Veteran did not have diabetic retinopathy which would be secondary to Agent Orange exposure. During his December 2015 VA eye examiantion, the Veteran was diagnosed as having glaucomatous optic atrophy of the right eye, macular edema of the right eye, and combined form cataracts (bilaterally). It was also reported that the Veteran was blind in his right eye. The December 2015 VA examiner’s nexus opinion focused on the negative relationship between the Veteran’s current right eye disabilties and his service-connected diabetes mellitus, type II. It did not address the Veteran’s presumed in-service exposure to herbicides. In its July 2017 remand, the Board requested a medical opinion addressing the “causal” and “aggravation” elements of secondary service connection. The Board specifically asked the VA examiner to render an opinion as to whether it is “at least as likely as not” that the Veteran’s diagnosed right eye disabilities are causally related to or aggravated (permanently worsened beyond the natural course of the disabiltiy) by the Veteran’s diabetes mellitus or causally related to any traumatic brain injury or explosion over his head during serivce. In September 2017, an addendum medical opinion responsive to the Board’s remand directives was provided. Specifically, the VA examiner’s nexus opinion focused on the negative relationships between the Veteran’s current eye disabilites and his service-connected diabetes mellitus, type II, as well as his claimed traumatic brain injury or exposion over his head during service. It did not address the Veteran’s presumed in-service exposure to herbicides. Before this matter can be adjudciated, additional development is needed. The Board acknowledges that none of the currently diagnosed right eye disabilites resulting in loss of vision are on the list of presumptive conditions associated with Agent Orange exposure. See 38 C.F.R. § 3.309(e). Notwithstanding the foregoing, the Federal Circuit has held that a claimant is not precluded from establishing service connection for a disease averred to be related to herbicide exposure, as long as there is proof of such direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). To ensure that all possible avenues of inquiry have been addressed, the RO must obtain a supplemental medical opinion as to whether any of the Veteran’s current right eye disabilities are “at least as likely as not” related to his presumed exposure to herbicides during active duty service in the Republic of Vietnam. 2. Entitlement to service connection for hypertension (claimed as high blood pressure), to include due to in-service herbicide exposure, and to include as secondary to service-connected diabetes mellitus, type II. In its August 2013 rating decision and December 2015 statement of the case, the RO found that the evidence of record is negative for any treatment or clinical diagnosis of hypertension. The Veteran was afforded a VA heart examination in May 2010. The examiner noted that the Veteran had a history of hypertension – for approximately 10 years – which was controlled with atenolol and hydrochlorothiazide. This assertion is supported by findings of essential hypertension in the Veteran’s private treatment records. This evidence contradicts the determination that the evidence of record is negative for any treatment or clinical diagnosis of hypertension. Additionally, the Board notes that the RO obtained a medical opinion regarding the Veteran’s documented “essential hypertension” in July 2017. The VA examiner noted that the Veteran was diagnosed with hypertension 10 years prior to the May 2010 VA examination. The examiner opined that “it is less likely than not that there is any causal relationship or aggravation involved” because “there is nothing in the available medical records indicating that the Veteran’s current diabetes has anything to do with his hypertension.” This rationale is inadequate because it does not explain why diabetes mellitus, type II, cannot cause or aggravate hypertension. The examiner should have supported his opinion with objective medical findings or studies. Under these circumstances, the RO must schedule the Veteran for a VA hypertension examination to ascertain whether he has a clinical diagnosis of hypertension. If a clinical diagnosis of hypertension is made, the examiner must indicate the approximate timeframe regarding the onset of that hypertension. If a clinical diagnosis of hypertension is made, the examiner must provide a medical opinion addressing (1) whether the Veteran’s hypertension is “at least as likely as not” related to his military service, to include his presumed exposure to herbicides during his service in the Republic of Vietnam, (2) whether the Veteran’s hypertension is “at least as likely as not” proximately due to or the result of his service-connected diabetes mellitus, type II, and (3) whether the Veteran’s hypertension is “at least as likely as not” aggravated beyond natural progression by his service-connected diabetes mellitus, type II. The examiner must provide adequate rationale for all medical conclusions reached. These matters are REMANDED for the following actions: 1. Contact the Veteran and ask him to identify whether there are any outstanding VA or private medical records reflecting treatment of his right eye disability or hypertension/high blood pressure. If such records are identified, then obtain those records and associate them with the electronic claims file. To expedite this action, the Veteran is encouraged to submit any additional VA or private medical records in his possession. 2. Obtain a supplemental medical opinion from an appropriate clinician regarding whether any of the Veteran’s current right eye disabilities are “at least as likely as not” related to his presumed exposure to herbicides during active duty service. The Board notes that initial findings of optic neuropathy were made in 2003, before the Veteran was diagnosed with diabetes mellitus, type II. All medical conclusions must be supported by adequate rationale. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension. If a clinical diagnosis of hypertension is made, the examiner must indicate the approximate timeframe regarding the onset of that hypertension. If a clinical diagnosis of hypertension is not made, the examiner must reconcile that finding with the private medical evidence of record indicating that the Veteran has “essential hypertension.” If a clinical diagnosis of hypertension is made, the examiner must provide a medical opinion addressing: (1) whether the Veteran’s hypertension is “at least as likely as not” related to his military service, to include his presumed exposure to herbicides during his service in the Republic of Vietnam; (2) whether the Veteran’s hypertension is “at least as likely as not” proximately due to or the result of his service-connected diabetes mellitus, type II; and (3) whether the Veteran’s hypertension is “at least as likely as not” aggravated beyond natural progression by his service-connected diabetes mellitus, type II. The examiner must provide adequate rationale for all medical conclusions reached. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. L. Marcum, Counsel