Citation Nr: 18152864 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 15-14 028 DATE: November 26, 2018 REMANDED Entitlement to service connection for a left eye disability is remanded. Entitlement to service connection for Sjogren’s syndrome is remanded. Entitlement to service connection for a thyroid disability, to include as due to radiation exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1985 to August 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from May 2014 and July 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded the claims in August 2017 for additional development, to include obtaining Social Security Administration (SSA) records and VA opinions. 1. Entitlement to service connection for a left eye disability is remanded. The Veteran contends that she has a left eye disability that is related to service, to include exposure to toluene. In a June 2016 VA examination report, the examiner noted diagnoses of peripheral retinal hole, posterior vitreous detachment in the left eye, and dry eye syndrome. He stated that the medical literature noted no association between atrophic retinal holes and toluene exposure; and that peripheral retinal holes generally occurred de novo. In its August 2017 remand, the Board found the opinion inadequate because the VA examiner failed to “failed to fully address direct service connection as to whether the Veteran’s diagnosed left eye disorders were related to or had their onset during service.” The Board requested an addendum opinion discussing whether any left eye disability was at least as likely as not related to service, to include toluene exposure, and to provide a complete rationale. In an August 2018 opinion, the VA examiner opined that it was less likely than not that a left eye disability was related to service because the disabilities were diagnosed after military service, as noted by record review. The Board finds this opinion inadequate as the VA examiner failed to provide a complete rationale for his opinion. See also Barr v. Nicholson, 21 Vet. App. 30 (2007) (holding that once VA undertakes the effort to provide an examination or obtain medical opinion, it must ensure that one is provided or obtained that is adequate for the determination being made). In addition, the Board notes that VA treatment records in August 2016 reflect that the Veteran took Plaquenil to treat her Sjogren’s syndrome, which could be a risk factor for eye disabilities. However, there is no VA opinion addressing whether any left eye disability is associated with Sjogren syndrome treatment. Therefore, a remand is required for a VA opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for Sjogren’s syndrome is remanded. The Veteran contends that she has Sjogren’s syndrome that is related to service, to include exposure to radiation. A June 2016 VA examination report reflects diagnosis of Sjogren’s syndrome in July 2012 and the Veteran’s allegations that it was related to environmental exposure during service. The VA examiner opined that Sjogren’s syndrome was less likely than not related to service because the Veteran reported she was in good health at her separation examination and there was no chronicity or continuity of care evident for over 20 years. However, the examiner did not address whether Sjogren’s syndrome was at least as likely as not due to environmental exposure, to include radiation. Therefore, a remand is required for a VA opinion addressing the nature and etiology of the Veteran’s claim. See also Barr, 21 Vet. App. at 30. 3. Entitlement to service connection for a thyroid disability, to include as due to radiation exposure is remanded. The Veteran contends that she has a thyroid disability that is related to service, to include exposure to radiation. Post-service VA treatment records in April 2013 reflect decreased TSH levels and assessment of possible subclinical hypothyroidism. Records in August 2017 reflect a medical history of nonspecific abnormal results of function study of thyroid. In September 2017, a VA physician noted that the Veteran’s TSH fluctuated from low normal to slightly low since 2012; and noted differential diagnoses of mild Graves, transient thyroiditis, warm nodule, or mild autonomously functioning goiter. The examiner also noted that these thyroid levels “could possibly be normal for her” since, “interestingly, African-Americans average slightly lower TSH.” Given the Veteran’s allegations that she has a thyroid disability related to radiation exposure during service; VA treatment records reflecting differential diagnoses of mild Graves, transient thyroiditis, warm nodule, or mild autonomously functioning goiter; and the fact that there is no VA examination or opinion addressing the nature and etiology of any thyroid disability, a remand for a VA examination and opinion by an appropriate physician is necessary. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see McLendon, 20 Vet. App. at 81. The matters are REMANDED for the following action: 1. Refer the Veteran’s claim for a left eye disability to an appropriate physician, to address the nature and etiology of the Veteran’s diagnosed peripheral retinal hole, posterior vitreous detachment in the left eye, and dry eye syndrome. The entire claims file, and a copy of this remand, must be provided to and reviewed by the examiner. The VA examiner should address whether any left eye disability is at least as likely as not (50 percent probability or more) related to or caused by service, to include exposure to toluene; or related to the Veteran’s Sjogren’s syndrome and treatment. The examiner must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. 2. Refer the Veteran’s claim to an appropriate physician for a medical opinion addressing the nature and etiology for Sjogren’s syndrome. The examiner should be provided with the Veteran’s claims file, including a copy of this REMAND. After reviewing the claims file, the examiner should address whether Sjogren’s syndrome is at least as likely as not (i.e. a 50 percent or greater probability) caused or otherwise related to the Veteran’s service, to include exposure to radiation. In answering these questions, the examiner should also address the Veteran’s competent assertions that she has experienced symptoms of Sjogren’s syndrome since service, and should specifically set forth the medical reasons for accepting or rejecting the Veteran’s statements regarding continuity of symptoms since her military service. The examiner must provide a complete rationale upon which his or her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Board notes that the lack of diagnosis during service or for several years thereafter cannot, alone, be the sole basis for the examiner’s opinion. 3. Schedule the Veteran for a VA examination for a medical opinion addressing the nature and etiology of any thyroid disability. The examiner should be provided with the Veteran’s claims file, including a copy of this REMAND. After reviewing the claims file and thoroughly examining the Veteran, the examiner should address whether any thyroid disability is at least as likely as not (i.e. a 50 percent or greater probability) caused or otherwise related to the Veteran’s service, to include exposure to radiation. (Continued on the next page)   The examiner must provide a complete rationale upon which his or her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel