Citation Nr: 18148437 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 13-18 725A DATE: November 7, 2018 ORDER Entitlement to service connection for blurred vision is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for thrombocytosis, previously referred to as thrombocytopenia, and claimed as high platelets and thrombosis is denied. Entitlement to service connection for restless leg syndrome and myoclonus, previously referred to as seizures, and claimed as constant jerking of the upper and lower limbs is denied. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a disability of the bilateral lower extremities, previously referred to as neuropathy, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has blurred vision due to a disease or injury in service, to include specific in-service event, injury, or disease. 2. The preponderance of the evidence is against a finding that the Veteran has obstructive sleep apnea, and against a finding that the Veteran’s sleep disorder is a disorder separate from his PTSD. 3. The preponderance of the evidence is against finding that the Veteran has thrombocytosis due to a disease or injury in service or a specific in-service event, injury, or disease, to include herbicide exposure. 4. The Veteran’s restless leg syndrome and myoclonus are neither proximately due to nor aggravated beyond their natural progression by his service-connected PTSD, and are not otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for blurred vision are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for obstructive sleep apnea are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for thrombocytosis are not met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a); 3.309. 4. The criteria for service connection for restless leg syndrome and myoclonus are not 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 served on active duty from August 1965 to August 1968 and from November 1968 to June 1972, including service in the Republic of Vietnam. He testified at a video conference Board hearing in March 2016. The transcript is of record. Service Connection 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, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 1. Entitlement to service connection for blurred vision The Veteran contends that his blurred vision is related to his exposure to flash grenades and artillery fire in service. The Board concludes that while the Veteran has a current diagnosis of cataracts and pinguecula, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis began during service or is otherwise related to an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). VA examined the Veteran in May 2017. The examiner diagnosed bilateral cataracts and bilateral pinguecula. The examiner opined that the Veteran’s eye disorders were less likely than not related to service. The examiner reasoned that the Veteran’s eye sight was 20/20 upon enlistment and separation and the medical records do not mention an event, disease or trauma that would predispose him to cataracts. The examiner further noted that the pinguecula does not cause vision or visual field defects. Service records corroborate the report of the examiner with regard to the Veteran’s vision being 20/20. The Veteran was, however, referred to the optometry clinic in February 1966 due to complaints of blurred vision, and an additional optometry clinic note from June 1969 reported headaches caused by the sun and reading. The Veteran denied having eye trouble at separation and the examination at separation reported 20/20 vision. The Veteran testified that his eyes are very light sensitive. He attributed this sensitivity and blurriness to the firing or artillery during combat. Although there is evidence that the Veteran had at least some blurred vision during service, and the Veteran has some blurred vision and sensitivity to light now, the evidence does not contain a link between the symptoms. The Veteran’s currently diagnosed eye conditions are cataracts and pinguecula. Pinguecula, as the examiner reported, does not affect vision. Cataracts do affect vision, and cause blurriness, but the medical records indicated that the Veteran did not have cataracts during service and the examiner opined that the recorded events during service would not have predisposed the Veteran to developing cataracts later in life. Because the evidence does not link the Veteran’s service with his currently diagnosed eye conditions, service connection must be denied. 2. Entitlement to service connection for obstructive sleep apnea The Veteran contends that his sleep apnea is another symptom of his PTSD. The Board concludes that the Veteran does not have a current diagnosis of sleep apnea and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran testified that his complaints of sleep apnea are really difficulties with his PTSD. A May 2016 problem list identified “sleep disorder, sleep apnea” as one of several problems. VA examined the Veteran in May 2017. The examiner reported that the examination did not provide evidence of sleep apnea. The examiner instead opined that the Veteran was describing symptoms of insomnia based on environmental conditioning in service. As the Veteran does not have a diagnosis of sleep apnea, service connection for sleep apnea, secondary to PTSD or otherwise, must be denied. Reference is made to the examiner’s finding that the Veteran experienced insomnia. However, the insomnia has been identified as a symptom of the Veteran’s PTSD as opposed to t a stand-alone disorder. The sleep disturbances are best considered as an element when rating the Veteran’s PTSD, which is the subject of a separate appeal. 3. Entitlement to service connection for thrombocytosis, previously referred to as thrombocytopenia, and claimed as high platelets and thrombosis The Veteran contends that his thrombocytopenia is due to his exposure to herbicides, including Agent Orange in Vietnam and that he experienced symptoms in 1970 or 1971. The Board concludes that while the Veteran has a current diagnosis thrombocytosis, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis began during service or is otherwise related to an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Board further concludes that the Veteran’s thrombocytosis was not at least as likely as not due to herbicide exposure. 38 U.S.C. § 1116; 38 C.F.R. § 3.309. Service records do not include a diagnosis or thrombocytosis or identify any disorder of the platelets. Moreover, the service records indicate that the Veteran did have bloodwork performed while in service including at least one complete blood count (CBC) in May 1971. A CBC is “the determination of the number of red blood cells (erythrocytes), white blood cells, and platelets . . .” Mosby’s Dental Dictionary, 2nd edition. S.v. “count, blood, complete.” Although not conclusive, the presence of such blood work in the Veteran’s service records is strong evidence that the Veteran did not have abnormal platelet counts at the time, as an abnormal reading would reasonably be expected to have been included in the results. The Veteran testified that he was treated for a blood condition in 1971. This is somewhat corroborated by the service records mentioned above, which indicate a number of blood tests in 1971. However, despite the blood testing, including the CBC testing, the service records do not include a diagnosis or any indication of a platelet disorder or some other disorder that may be related to his current diagnosis. More recent medical records indicate that the Veteran has thrombocytosis, but the diagnosis appears to have been made in the 2000s, not in the 1970s. Although thrombocytosis is not a condition presumed to be herbicide related, the Veteran served in Vietnam and is presumed to have been exposed to herbicides. Accordingly, if the Veteran can show actual causation between herbicides and his later developed condition, he may still be awarded service connection. 38 U.S.C. § 1116; 38 C.F.R. § 3.303. The Veteran’s representative cited to a National Institute of Health website for the proposition that exposure to toxic chemicals such as pesticides can slow the production of platelets, which the representative asserted could lead to thrombocytopenia. In a letter dated May 2018, a hematologist opined that the website article was not applicable to this situation. According to the hematologist the Veteran has essential thrombocythemia, which is characterized by excessively high platelet counts, and not thrombocytopenia, which is characterized by low platelet count. Because the representatives article indicated that toxic chemicals lowered platelet production it would not result in the Veteran’s high platelet count. The hematologist further opined that there was no known connection between the Veteran’s condition, essential thrombocytosis, and exposure to herbicides such as Agent Orange. Moreover, the hematologist opined that the symptoms of dizziness, headache, vision changes, and fainting that the Veteran experienced during service were general symptoms and were not specific to a particular etiology. Considering the blood testing from the service records, together with the non-specific nature of the in-service symptoms and the lack of a connection between herbicide exposure and thrombocytosis, service connection must be denied. 4. Entitlement to service connection for restless leg syndrome and myoclonus, previously referred to as seizures, and claimed as constant jerking of the upper and lower limbs The Veteran contends that his jerking of the limbs is related to his service-connected PTSD. The Board concludes that, while the Veteran has a current diagnosis of bilateral restless leg syndrome and myoclonus, the preponderance of the evidence is against finding that the Veteran’s disability is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The May 2017 VA examiner opined that the Veteran’s bilateral restless leg syndrome and myoclonus were the result of an unknown etiology typically associated with cigarette smoking, fibromyalgia, Parkinson’s disease, and/or vitamin deficiency. According to the examiner, there was no link in the medical literature between restless leg syndrome or myoclonus to either herbicide agent exposure or PTSD. The examiner further explained that restless legs syndrome is something that either exists or doesn’t; it could not have been aggravated by PTSD or any other disability from service. Although the Veteran believes that his restless legs syndrome and myoclonus are the result of his PTSD, he does not have medical training or base his opinion on medical evidence. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the May 2017 examiner. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s bilateral restless legs syndrome and myoclonus is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service treatment records do not record incidents of shaking or restless legs during service or at discharge. The Veteran’s spouse wrote in June 2013 that after he returned home from Vietnam in 1972 his legs would shake when he went to sleep, but in various medical notes, the Veteran reported that his involuntary jerking movement began after Vietnam and gave an estimate of 20 years (roughly 1989) as the onset. Although the Veteran is competent to report the shaking and twitching in his legs associated with restless legs syndrome and myoclonus, his reports consistently put the onset of the symptoms decades after service. Together with the examiner’s conclusion that the Veteran’s restless leg syndrome and myoclonus were not incurred in or caused by service, the weight of the evidence is against service connection. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability is remanded. VA most recently examined the Veteran in May 2017. The examiner diagnosed the Veteran with a knee strain, but no degenerative changes were seen on his diagnostic testing. The examiner opined that the Veteran’s knee problems were attributable to a related problem, such as a shift in gait dependence. This opinion is insufficient. The Veteran is service connected for disabilities of both ankles. It is within the realm of possibility that the Veteran’s ankle disabilities could be the cause of a gait dependence mentioned by the examiner. An opinion as to secondary service connection is required. 2. Entitlement to service connection for neuropathy of the bilateral lower extremities is remanded. The May 2017 VA examiner opined that the Veteran did not have neuropathy of the bilateral lower extremities. However, he did report that the Veteran had symptoms of paresthesias, dysesthesias or numbness. The Veteran is only required to identify symptoms of a disability. He is not required to identify the specific disability. The May 2017 VA examiner did not opine on whether the symptoms represented a disability other than neuropathy. Accordingly, a remand is required to address alternative diagnoses. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The Veteran’s claim for TDIU is inextricably intertwined with his other remanded claims. Accordingly, it too must be remanded. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left knee disability is at least as likely as not proximately due to his other service-connected disabilities including his left and right ankles or aggravated beyond its natural progression by service-connected disability. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any leg paresthesias, dysesthesias or numbness. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including repeated parachute landings. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Paul Saindon, Associate Counsel