Citation Nr: 18152195 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 17-58 228 DATE: November 21, 2018 REMANDED Entitlement to service connection for lumbar spine disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for eye disability, to include double vision and glaucoma, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1971 to March 1980 and March 1980 to May 2001. 1. Entitlement to service connection for lumbar spine disability is remanded. 2. Entitlement to service connection for left knee disability is remanded. 3. Entitlement to service connection for left ankle disability is remanded. 4. Entitlement to service connection for eye disability, to include double vision and glaucoma, is remanded. The Veteran underwent VA examination in September 2016. The VA examiner opined that the Veteran’s lumbar strain is less likely than not incurred in or caused by service. The VA examiner explained that there was no medical evidence to show a back injury in service as the Veteran’s service treatment records were silent for back complaints. However, the Veteran’s service treatment records show treatment for a November 1987 back strain. Moreover, the VA examiner did not address the Veteran’s reports regarding pain in service and his contention that his back condition is related to excessive physical activities during service. Accordingly, remand is appropriate for further VA medical opinion regarding the Veteran’s lumbar spine disability. The VA examiner also opined that there was no left knee or left ankle diagnosis at the time of the examination. However, the Veteran submitted a May 2017 Womack Army Medical Center treatment record showing a diagnosis of left knee arthritis. In addition, the Veteran reported left ankle functional impairment at the time of the VA examination. Accordingly, remand is appropriate for VA medical opinion regarding whether the Veteran’s left knee and left ankle disabilities are related to service. The Board also cannot make a fully-informed decision on the issue of entitlement to service connection for eye disability, because no VA examiner has opined as to whether the Veteran’s eye disability had an onset in service or is otherwise related to service. The treatment records show various diagnoses for the Veteran’s eye disability, and he asserts such conditions began in service or are related to service, to include treatment in service. The Veteran’s service treatment records show that he experienced eye problems in service. Accordingly, remand is appropriate for VA medical opinion regarding whether the Veteran’s eye disability had an onset in service or is related to service. The Veteran submitted some records from Womack Army Medical Center, but reported treatment that began in 2001. While this matter is on remand, outstanding   private and government treatment records should be obtained, including any additional treatment records from Dr. Mitchum, Carolina Eye Associates, and Dr. Carver-Schemper, and outstanding Womack Army Medical Center records from 2001 to the present. The matters are REMANDED for the following action: 1. After securing any necessary authorization, obtain any private treatment records as the Veteran may identify relevant to his claims, including any additional treatment records from Dr. Mitchum, Carolina Eye Associates, and Dr. Carver-Schemper. 2. Obtain additional Womack Army Medical Center treatment records from 2001 to the present. 3. After obtaining any outstanding records, ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The examiner should identify any current lumbar spine, left knee, and left ankle disability the Veteran has presented during the claim period (from April 2016 to the present). For each disability, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the disorder had an onset in service or is otherwise related to an in-service injury, event, or disease. For arthritis, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested to a compensable degree within a year of separation from service (by May 2002). The examiner should consider all medical and lay evidence of record. The Veteran reported that sharp lumbar spine pain and aching knee and ankle pain began during service. He asserts that his current lumbar spine, knee, and ankle conditions are a long-term effect of strenuous physical activities during service, including ruck marches through rough terrain while carrying 30 to 50-pound loads, physical training while wearing combat boots, and airborne operations. He also reports that he injured his ankle and back multiple times during service. The Veteran’s service treatment records show treatment for ankle and lumbar spine problems. If the Veteran’s reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). A complete rationale should be given for all opinions and conclusions expressed. 4. After obtaining any outstanding records, ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The examiner should identify any current eye disability the Veteran has presented during the claim period (from April 2016 to the present). For each disability, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the disorder had an onset in service or is otherwise related to an in-service injury, event, or disease. The examiner should consider all medical and lay evidence of record. The Veteran reported that he has experienced double vision, blurred vision, dry eye, and halo effect since treatment in service. The Veteran’s service treatment records show treatment for eye problems, including Lasik surgery. If the Veteran’s reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). A complete rationale should be given for all opinions and conclusions expressed.   5. After the above development, and any other development deemed necessary, readjudicate the claims. If the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Purcell, Associate Counsel