Citation Nr: 18142354 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 16-25 866 DATE: October 15, 2018 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for left eye disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1957 to December 1960. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by a Department of Veterans Affairs Regional Office (RO). In July 2018, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. 1. Entitlement to compensation under 38 U.S.C. § 1151 for left eye disability is remanded. The Veteran asserts entitlement to service connection for a left eye disability. Specifically, the Veteran asserts that his current left eye disability resulted from lack of care and/or an injury sustained as a result of surgical treatment received at his VA medical center. A review of the evidence of record shows that the Veteran established medical care at his VA medical center in February 2012. The Veteran was noted to have elevated cholesterol, left eye cataracts and that he had had a heart attack. A March 2012 VA medical record noted the Veteran reported being told he had cataracts and that he had a hard time seeing out of his left eye. The Veteran requested a consultation with the eye clinic. In April 2012, the Veteran reported that he was going to have outside cataract surgery. In August 2012, the Veteran was assessed with suspect glaucoma and macular edema. The Veteran underwent left eye laser surgery in September 2012 to treat fluid that was trapped behind the iris. The surgery created an opening in the iris to allow fluid to drain. The Veteran also underwent left eye cataract laser surgery in November 2012. Additionally, in November 2012, the Veteran was assessed with suspected ocular ischemic syndrome in the left eye with early neovascular glaucoma. The Veteran was noted to have documented ischemia during an October 2012 cardiac stress test and a history of iliac stenting and other cardiac risk factors. In December 2012, the Veteran was found to have central retinal vein occlusion (CRVO) of the left eye with associated retinal hemorrhages, iris neovascularization and retinal neovascularization. The recent rise in intraocular pressure was noted as consistent with neovascular glaucoma. Left eye panretinal photocoagulation laser surgery was performed. Thereafter, the Veteran underwent eye injections to treat his CRVO in March, April, May, July and August 2013. A private September 2018 eye examination shows the Veteran reported that he lost vision in his left eye due to glaucoma. The physician noted a retinal tear in the left eye with prior retinal surgery. In addition, the physician noted vision loss in the left eye due to prior retinal damage. The Veteran was diagnosed with chorioretinal scars after surgery for detachment, left eye. Under VA laws and regulations, when a Veteran suffers additional disability or death as a result of training, hospital care, medical or surgical treatment, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such disability or death was service-connected. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.358, 3.361. A claimant is required to show fault or negligence in medical treatment. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran’s additional disability or death. Merely showing that a Veteran received care, treatment, or examination and that that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA’s failure to timely diagnoses and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). The Board notes that to date, the Veteran has not been afforded a VA examination and the Board finds that a remand to undergo a medical examination and to obtain an appropriate medical opinion is necessary to properly adjudicate the issue on appeal. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, the Veteran should be scheduled for a VA eye examination. The entire claims file including a copy of this remand should be reviewed by the examiner. For the claim of entitlement to compensation under 38 U.S.C. § 1151, the examiner should provide the following opinions: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has a left eye disability(ies) as a result of the medical care, or a lack thereof to include failure to timely diagnose or treatment, received at the VA medical center between February 2012 and August 2013, to include as a result of surgeries performed. Please explain why or why not. In particular, the examiner should address the Veteran’s contention that VA failed to properly treat his eye disability because he waited too long to be seen. The examiner should review the body of his remand for a summary of the Veteran’s eye treatment. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that any additional left eye disability(ies) was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part (i.e. did VA fail to exercise the degree of care that would be expected of a reasonable healthcare provider)? Please explain why or why not. (c) Notwithstanding the acknowledgement of informed consent, based upon the specific facts and circumstances of this Veteran’s case, was any additional left eye disability(ies) a reasonably foreseeable outcome of the treatment received, including the left eye surgeries? Please explain why or why not. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner cannot provide an opinion without resorting to mere speculation, please provide a complete explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that you have exhausted the limits of current medical knowledge in providing an answer to that particular question. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel