Citation Nr: 18144832 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 16-20 309 DATE: October 25, 2018 ORDER Entitlement to service connection for diabetic retinopathy is granted. Entitlement to service connection for erectile dysfunction is granted. REMANDED Entitlement to service connection for a disability manifested by visual impairment, other than diabetic retinopathy, is remanded. Entitlement to service connection for a heart disability is remanded. FINDINGS OF FACT 1. The Veteran’s diabetic retinopathy is proximately due to service-connected diabetes mellitus type II. 2. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s erectile dysfunction is proximately due to service-connected diabetes mellitus type II. CONCLUSION OF LAW 1. The criteria for secondary service connection for diabetic retinopathy have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for secondary service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1966 to June 1969; he served in Vietnam from December 1967 to December 1968. Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in active military service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury pursuant to 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Initially, the Board notes that service connection has been established for diabetes mellitus type II and prostate cancer as a result of his presumed Agent Orange exposure during active service in Vietnam.   1. Entitlement to service connection for diabetic retinopathy The Veteran contends that he has vision problems as a result of his presumed Agent Orange exposure during active service in Vietnam. Upon review of the record, the Board agrees and finds that service connection is warranted based on secondary service connection. First, the Board finds that the Veteran has a current disability of the eyes, which satisfies the first prong of service connection. Next, the Board finds that the Veteran has satisfied the second prong of secondary service connection, which is that the Veteran has a service-connected disability. Finally, the nexus component of secondary service connection has been satisfied, where a private medical record from Dr. M. T., indicates that in June 2013, the Veteran had vitreous floaters, senile macular degeneration (aging), nuclear sclerosis cataract, diabetic retinopathy, diabetes with ocular involvement, glaucoma suspect, and nonproliferative diabetic retinopathy. See June 2013, Dr. M. Turner, Optometry. The Board notes that there is a February 2013 VA medical opinion and a March 2015 medical opinion. See February 2013, Eye Conditions Disability Benefits Questionnaire (DBQ) and March 2015, Eye Conditions DBQ. However, both opinions have minimal probative value as to deciding whether the Veteran should be service connected, where the February 2013 VA medical opinion did not consider that the Veteran had diabetes, and the March 2015 medical opinion was not definitive as it pertained to the Veteran’s diabetes, providing a speculative opinion. The optometrist noted that she was not provided with “examination records” and noted no evidence of a diagnosis of diabetes was made available to her and that it was not possible to determine the etiology of the optic atrophy without resorting to speculation. In sum, the Board finds that the weight of the evidence supports a finding that the Veteran's service-connected diabetes mellitus proximately caused the Veteran’s eye disability. In so finding, the Board acknowledges the March 2015 VA examiner’s opinion. However, given the tentative nature of this opinion, particularly in contrast to the positive opinion submitted by the Veteran's private physician, the Board finds that the evidence weighs in favor of his claims. Resolving reasonable doubt in the Veteran's favor, his claim will be granted. See 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for erectile dysfunction The Veteran contends that he has erectile dysfunction as a result of his presumed Agent Orange exposure during active service in Vietnam. The Board agrees. The Board finds that the first prong of secondary service connection has been satisfied, as there is evidence of erectile dysfunction. As to the second prong of secondary service connection, this has been satisfied as well because the Veteran’s diabetes is service connected. As to the third prong, the Veteran underwent a VA examination for diabetes mellitus in March 2015, which reflects that there is a connection between the Veteran’s erectile dysfunction and his service-connected diabetes mellitus. The examiner stated: “This patient has numerous medical conditions [hypertension, peripheral arterial disease, and diabetes] that can cause or contribute to ED. . . . All of these medical conditions can contribute to/or cause ED. There is no accurate method to determine a baseline and/or a percentage contribution of any of these medical conditions to his ED without resorting to speculation. See March 2015, Diabetes Mellitus DBQ. As a VA examiner has clearly suggested that the Veteran’s service-connected diabetes mellitus has potentially caused or contributed to his erectile dysfunction, and as there is no contradictory evidence of record, the Board is satisfied that the criteria for entitlement to service connection for erectile dysfunction, pursuant to the provisions of 38 C.F.R. § 3.310, have been met. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 U.S.C. 5107 (b); 38 C.F.R. § 3.102. Thus, resolving reasonable doubt in the Veteran’s favor, his claim will be granted. See 38 U.S.C. § 5107 (b). REASONS FOR REMAND 3. Entitlement to service connection for a disability manifested by visual impairment other than diabetic retinopathy The Veteran’s service treatment records indicate that he entered service without complaints, findings, or diagnoses of any eye disorders; and on physical examination in June 1966 for entrance into service, his eyes, ophthalmoscopic, pupils, ocular motility were evaluated as normal. His distant vision was 20/20 in both eyes, and his near vision was J-1 in both eyes. At separation from service, the Veteran reported eye trouble; the examiner noted eye trouble in the past, no sequelae. On physical examination for separation from service in March 1969, his eyes, ophthalmoscopic, pupils, ocular motility were evaluated as normal. His distant vision was 20/20 in both eyes, there was no imbalance on cover test, and intraocular tension was normal. As noted above, in addition to the now-service connected diabetic retinopathy, the Veteran has been diagnosed as having visual impairment and nuclear sclerosis cataracts, optic atrophy of both eyes, vitreous floaters, and senile macular degeneration. Private medical records indicate that in June 2013, in addition to the nonproliferative diabetic retinopathy, the Veteran also had “diabetes with ocular involvement.” This indicates a possible relationship between another eye disability and the Veteran’s diabetes mellitus. Although the Veteran has undergone two VA examinations to determine the etiology of any current eye disability; the examining optometrist did not offer an opinion regarding whether the Veteran’s eye disabilities are in any way related to his active duty service or whether they are aggravated by his service-connected diabetes. As such, an additional examination is needed to address whether any current eye disability, other than diabetic retinopathy, is in any way related to active service or to service-connected disability. 4. Entitlement to service connection for a heart disability The Veteran underwent VA heart conditions examination in March 2015 at which time the examiner, a VA physician, noted that the Veteran did not have or had never been diagnosed with a heart condition. The physician noted that she did not review the Veteran’s claims file but did review VA treatment records and civilian medical records. The Veteran’s service treatment records indicate that in March 1970, less than one year after his discharge from service, the Veteran was medically disqualified for reenlistment in the Army by reason of cardiomegaly and ischemic changes on electrocardiogram. Private treatment records indicate that on chest x-ray in June 2013, the Veteran’s heart size was within normal limits. On chest x-ray in May 2014 showed that the Veteran’s heart was mildly enlarged. The Board finds that the March 2015 VA heart examination is inadequate as the examiner does not appear to have reviewed all of the Veteran’s records, did not address the findings of enlarged heart on x-ray in May 2014, and did not address the findings of cardiomegaly and ischemic changes in March 1970. Thus, it is the Board’s opinion that an additional examination be conducted to determine the etiology of any current heart disability. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician, preferably an ophthalmologist, to determine the nature and etiology of any current eye disabilities. For each eye disorder identified (except for the diabetic retinopathy), the examiner must opine (1) whether it is at least as likely as not related to an in-service injury, event, or disease; or (2) whether it is at least as likely as not (i) proximately due to service-connected disability including treatment for such, or (ii) aggravated beyond its natural progression by service-connected prostate cancer or diabetes mellitus type II including treatment for such. 2. Schedule the Veteran for an examination by an appropriate clinician, preferably a cardiologist, to determine the nature and etiology of any current heart disability. For any heart disorder identified, the examiner must opine (1) whether it at least as likely as not had its onset in service or within a year following service; or disease; or (2) whether it is at least as likely as not (i) proximately due to service-connected disability or treatment for such, or (ii) aggravated beyond its natural progression by service-connected prostate cancer or diabetes mellitus type II including treatment for such. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Olson, Counsel