Citation Nr: 18147360 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 16-17 786 DATE: November 5, 2018 REMANDED Entitlement to service connection for a left eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the Marine Corps from February 2009 to February 2013, including service in Afghanistan. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for a left eye disorder (listed as a left eye abrasion). The Veteran contends that she has a left eye disorder that is related to service. She specifically maintains that she suffered a left eye injury during physical training when she was kicked in the left eye. The Veteran reports that she suffered a possible laceration or severe abrasion to the cornea, at that time, and that her treatment included using medicated eye drops and ointment, as well as wearing a patch for two weeks. She indicates that while serving in Afghanistan, a sand storm caused debris to be blown into her left eye, and that there was ongoing irritation in that eye. The Veteran essentially asserts that she has ongoing problems with her left eye that began during her period of service. The Veteran is competent to report that she had left eye problems during and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As noted above, the Veteran served on active duty in the Marine Corps from February 2009 to February 2013, including service in Afghanistan. Her DD Form 2014 indicates that she served two tours of duty in Afghanistan from February 2010 to August 2010, and from January 2012 to June 2012. The RO has conceded that the Veteran received treatment for a left eye condition during service. The Veteran’s service treatment records indicate that she was treated for left eye problems on several occasions. An August 2009 treatment entry notes that the Veteran was seen for possible pink eye. She reported that she had severe pain, which she described as a nine out of ten, in the left eye. The assessment was inflammation of the orbit. A subsequent August 2009 treatment entry notes that the Veteran’s medical history included an acute inflammation of the orbit. The assessment was epidemic keratoconjunctivitis. The examiner reported that the epidemic keratoconjunctivitis was improving in the left eye, with an improving subepithelial (corneal) infiltrate, and less discomfort. Another August 2009 entry, on that same day, relates an assessment of epidemic keratoconjunctivitis. A June 2011 Post Deployment Health Reassessment Report notes that, following a six-month deployment in Afghanistan, the Veteran indicated that she had watery, red, eyes that she felt were related to her deployment. Diagnoses were not provided at that time. On a medical history form at the time of a January 2013 separation examination, the Veteran checked that she had an eye disorder, or eye trouble, and that she underwent surgery to correct her vision. The Veteran specifically reported that she had problems with a stye following her deployment, which caused her to have eye surgery. The reviewing examiner indicated that the Veteran’s eye complaints were not considered disabling. The objective January 2013 VA separation examination report was apparently not of record. Post-service private and VA treatment records, including an examination report, do not specifically show treatment for a left eye disorder. A May 2016 VA eye conditions examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that her left eye symptoms began in “2010” during physical training when she was kicked in the left eye. She stated that she suffered a possible laceration or severe abrasion at that time. The Veteran indicated that her treatment included medicated eye drops and ointment, as well as wearing a patch for two weeks. She maintained that in 2012, while serving in Afghanistan, a sand storm caused debris to be blown into her left eye. The Veteran reported that she had ongoing irritation. The diagnosis solely referred to a congenital cataract of the right eye. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that a review of the complete medical records did not show treatment for a corneal abrasion. The examiner stated that the claimed condition resolved without residual effect. It was noted that the Veteran’s congenital cataract, of the right eye, did not affect visual acuity and did not requirement treatment, and that, by definition, was not a factor of any extraneous occurrence. The examiner maintained that there was no residual defect from past trauma or treatment to the Veteran’s eyes. The Board observes that the examiner reported that a review of the complete medical records did not show treatment for a corneal abrasion. The Board notes, however, that the Veteran’s service treatment records do show treatment for left eye problems. An August 2009 treatment entry relates an assessment of inflammation of the orbit (of the Veteran’s left eye), and a subsequent August 2009 treatment entry, includes a notation by the examiner that the epidemic keratoconjunctivitis was improving in the Veteran’s left eye, with an improving subepithelial (corneal) infiltrate, and less discomfort. The Board also observes that the examiner did not specifically address the Veteran’s reports of left eye problems during and since service. See Davidson, 581 F.3d at 1313. The Board further notes that, to the extent that the Veteran does not have a diagnosable disability, the VA must consider whether she has functional impairment for which service connection may be granted. See Saunders v. Wilkie, 886 F.3d 1356, 1363-64 (Fed. Cir. 2018) (indicating that the term “disability” refers to the functional impairment of earning capacity, rather than the underlying cause of the impairment, and pain alone may be a functional impairment). The Board observes that Saunders case was decided subsequent to the May 2016 VA eye conditions examination report. In light of the above, the Board finds that Veteran has not been afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to her claim for service connection for a left eye disorder. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated her for left eye problems since June 2018. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise her that she may obtain and submit those records herself. 2. Notify the Veteran that she may submit lay statements from herself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of her in-service and post-service symptomatology regarding her left eye problems. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination to determine the onset and/or etiology of her left eye problems. The claims file must be reviewed by the examiner. The examiner must diagnose all left eye impairment. The examiner must provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any left eye problems are related to and/or had their onset during her period of service. The examiner must specifically acknowledge and discuss the Veteran’s treatment during service for inflammation of the orbit of the left eye, and for epidemic keratoconjunctivitis of the left eye, and her reports of left eye problems, including a left eye injury, during service and since service. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel