Citation Nr: 18152503
Decision Date: 11/23/18	Archive Date: 11/23/18

DOCKET NO. 16-33 828
DATE:	November 23, 2018
REMANDED
Entitlement to service connection for a bilateral eye disorder including cataracts, as secondary to service-connected diabetes mellitus type II, is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the Army from March 1970 to October 1971.
1. Entitlement to service connection for a bilateral eye disorder including cataracts, as secondary to service-connected diabetes mellitus type II, is remanded.
The Veteran claimed service connection for a bilateral eye condition secondary to type II diabetes on Form 21-526b received in September 2011, which was accompanied by an Authorization for the Release of Medical Information form from Cleveland Clinic. On that form, the Veteran indicated that he was seen at Marymount Hospital, but no records request was made directly to the Cleveland Clinic Marymount Hospital facility. Cleveland Clinic’s response to the records request, received in October 2011, indicated that the Veteran was “not seen at main campus.” Directed development notes indicate an intention to provide a new form to the Veteran in order to make a records request from Marymount Hospital, and that letter was sent to the Veteran on December 19, 2012 (December letter). A letter concerning the Veteran’s election of direct deposit was sent to him at the same address as the December letter, and was returned as undeliverable in January 2013, indicating that the December letter likely did not reach the Veteran. 
In June 2013, a VA examiner indicated that she could not determine the etiology of the Veteran’s cataracts, as they had been removed, and there were no medical records available in the claims file concerning the cataracts. It is reasonable to infer that the Veteran did not receive the communication indicating that VA needed a further release from him in order to obtain the relevant medical records, and accordingly could not be expected to have provided such a release form. To ensure that VA has met its duty to assist the Veteran, the Board finds that remand is necessary to obtain outstanding medical records and a medical opinion. 38 C.F.R. § 3.159(c).
Further, VA treatment notes that the Veteran reported receiving treatment for his eyes from R. Burger, M.D. in 2011.  See VA treatment note, dated March 13, 2013.  On remand, his records from this provider should be obtained.
The matter is REMANDED for the following action:
1. Make arrangements to obtain the Veteran’s complete treatment records from R. Burger, M.D. and Marymount Hospital and/or Marymount Hospital Providers.
2. Make arrangements to obtain the Veteran’s complete treatment VA records, dated from January 2017, forward.
3. After receipt of the above records, arrange for an appropriate examiner to review the Veteran’s records and provide a medical opinion as to the etiology of any current eye disorder, including cataracts.  
Specifically, the examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) that any current eye disorder, including cataracts, was either (a) caused by, or (b) aggravated by the Veteran’s service-connected diabetes mellitus, type II.
 
P.M. DILORENZO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J. Haas, Associate Counsel