Citation Nr: 18157594 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 18-01 293 DATE: December 13, 2018 REMANDED Entitlement to service connection for a right eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) in the United States Army from March 1996 to August 1996. Immediately following active duty, the Veteran joined the United States Army Reserve until January 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. Entitlement to service connection for right eye disorder is remanded. A remand is required to have the RO schedule the Veteran for an examination to determine whether she has a right eye disorder, and if so, whether it is related to her period of ACUDTRA. See 38 U.S.C. § 5103A(d). There are four elements necessary in determining the need for a medical examination: (1) a current disability; (2) an in-service event, injury, or disease; (3) an indication that the claimed disability may be associated with the established event; and (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McClendon v. Nicholson, 20 Vet. App. 79, 81-85 (2006). The third prong, which requires the evidence of record “indicate” the claimed disability or symptoms “may be” associated with the established event, disease, or injury, is a low threshold. McLendon, 20 Vet. App. at 83. As to this claim, the Board finds the criteria set forth in McClendon have been met and that a VA examination and etiological opinion should be obtained. In this case, the Veteran contends she received a right eye injury during training and injured both eyes when her reserve unit was sent to Fort Irwin, California. Private medical records reflect the Veteran’s eye examinations date back to April 2003. These examinations indicate she has a consistent diagnosis of myopia (nearsightedness) and astigmatism (a common imperfection in the eye’s curvature). The evidence of record for eye examinations is silent from August 2009 until May 2012. Eye examinations dating 2012 to 2015 also note a diagnosis of myopia and astigmatism. Therefore, while refractive error of the eye is not a disability for VA disability compensation purposes under 38 C.F.R. § 4.9, giving the Veteran the benefit of the doubt, and given the consistent diagnosis of myopia and astigmatism on record that could be symptoms of possible disability, the Board preliminarily concludes that the Veteran has a current disability satisfying the first element of the McClendon test. As it pertains to the second element, the Veteran contends that during AIT, sometime between June 7 to August 7, 1996, her eye was accidentally grazed by another solider, causing a cornea abrasion (scratched eye). As a result, she was sent to the emergency room, prescribed antibiotic eyedrops for ten days, and put on a shades profile to protect her eyes while dilated. She further reports that both of her eyes were also injured due to sand blowing and grazing of her eyes. Although there is no supporting documentation in the Veteran’s service treatment records (STRs), it is well-documented in the Veteran’s eye examination reports that she has described these two incidents as being triggers for her eye problems. Therefore, the Board finds adequate evidence of an in-service injury to satisfy the second element of the McClendon test. In regard to the third element, the Veteran claims that the two in-service injuries have caused her vision to decline and caused pain in her eyes. Given the low threshold of the third element, and the Veteran’s consistent diagnosis of myopia and astigmatism, which may be symptoms of a possible disability related to her in-service injuries, the Board finds the third element satisfied. As for the final element, the Board cannot make a fully-informed decision on the issue of a right eye disability because no VA examiner has opined whether the Veteran is currently diagnosed with disability. No VA examiner has opined whether any current eye disorder might have begun during the Veteran’s service due to the cornea abrasion or the sand grazing her eyes—thus an appropriate examination is warranted. Parenthetically, the Board notes that it considered the probative value of the private chiropractor in this regard, it found that it was incomplete in two important respects. First, although the chiropractor found that the Veteran had residuals of a right eye injury, there was no diagnosis of that disability. As noted previously, myopia and astigmatism are not disabilities for VA benefits purposes without some relationship to a diagnosed eye disability. Secondly, no rationale was expressed linking any current eye disorder to the incidents reported by the Veteran. The matter is REMANDED for the following actions: 1. Provide the Veteran with an appropriate examination to determine whether she has a right eye disorder and if so, the nature and etiology of the disability. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. 2. If found to have a right eye disorder, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that its onset occurred in service or is caused by, or related at least in part, to the cornea abrasion and sand grazing incidents that occurred during the Veteran’s active duty for training or other recognized period of active military service. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Christopher J. DeBoer, Law Clerk