Citation Nr: 1817265 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 09-50 816 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for left eye glaucoma. REPRESENTATION Veteran represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD R. Gandhi, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from August 1983 to August 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The case was initially brought before the Board in January 2015, at which time the Board, in pertinent part, remanded the issue on appeal for further development. The matter was subsequently returned to the Board. In a July 2016 decision, the Board, in pertinent part, denied left eye glaucoma, to include as secondary to service-connected TBI and/or service-connected right eye disability. The Veteran appealed the July 2016 decision to the U.S. Court of Appeals for Veterans Claims (Court). In a March 2017 Order of the Court granting a March 2017 Joint Motion for Partial Remand (JMPR), the parties agreed to vacate that portion of the July 2016 Board decision that denied the Veteran's claim for service connection for left eye glaucoma, to include as secondary to service-connected TBI and/or service-connected right eye disability and remand the matter for compliance with the terms of the JMPR. In August 2017 the matter was remanded by Board for further evidentiary development. The matter has since returned to the Board. FINDING OF FACT Glaucoma of the left eye is not shown to be causally or etiologically related to any disease, injury, or incident during service, or to the service-connected TBI or service-connected right eye disability. CONCLUSION OF LAW The criteria for entitlement to service connection for left eye glaucoma have not been met. 38 U.S.C. 1111, 1131, 5107 (2012); 38 C.F.R. §3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran asserts that service connection for glaucoma of the left eye is due to an in-service motor vehicle accident in August 1986, which resulted in a TBI; or due to service-connected right eye disability. See April 2011 Statement. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link, or nexus, between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303 (2017). Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen v. Brown, 8 Vet. App. 374 (1995). Service treatment records are negative for treatment or diagnosis of glaucoma of the left eye. Although the Veteran suffered an in-service motor vehicle accident, service treatment records from the motor vehicle accident do not show any injury to the left eye or a diagnosis of glaucoma. See December 2009 Treatment Records. During a June 2011 VA examination, a history of left eye glaucoma was diagnosed. The examiner indicated that left eye glaucoma was not caused by or a result of, or permanently aggravated by the service-connected right eye disability as there is no medical rational mechanism for the right eye cataract surgery to cause or aggravate left eye glaucoma. The Veteran was afforded another VA eye examination in October 2012 to assist in determining whether his currently diagnosed left eye glaucoma was related to his service-connected TBI disability. The examiner stated that "at this point in time there is no evidence to suggest that traumatic brain injury can cause or aggravate glaucoma." For this reason, the examiner opined that the Veteran's left eye glaucoma was less likely than not related to the service-connected TBI disability. In January 2013 the Veteran submitted medical literature that suggested a possible relationship between brain injuries and glaucoma. In a February 2015 VA opinion, the examiner indicated after a review of all the pertinent evidence, that the Veteran's left eye glaucoma was less likely than not due to TBI as the Veteran did not have any direct trauma to his left eye (as opposed to evidence that showed direct trauma to the right eye). He indicated that the Veteran has had elevated intraocular pressures noted many times in the left eye which was likely the cause of his glaucoma. The examiner further noted, there was also no evidence of angle recession in the left eye that would explain elevated intraocular pressure in the left eye caused by trauma. He noted that blunt trauma can certainly lead to damage to the angle of the eye which regulates pressure, however, there was no evidence to suggest angle damage due to trauma in the Veteran's left eye. Therefore, the Veteran's glaucoma was less likely as not caused by trauma to the left eye. In August 2017, following the March 2017 JMPR, the Board remanded the case because the February 2015 VA opinion failed to discuss the medical literature submitted by the Veteran in January 2013 and did not address the issue of secondary service connection for left eye glaucoma. A new opinion was sought. In October 2017 a VA examiner provided a new opinion. The examiner reviewed the Veteran's records, previous exams, and the January 2013 medical literature provided by the Veteran. This was done in conjunction with a senior VA staff clinical ophthalmologist, and the examiner based his opinion on that review. The examiner opined that based on a thorough review of all records, to include previous examinations and comments, private records, and a literature review, it is not at least as likely as not that the left eye glaucoma is etiologically related to active duty service. The examiner further reasoned that a review of the Veteran's service treatment records (STRs) did not indicate or support this relationship. The examiner also opined that it is not at least as likely as not the left eye glaucoma was caused by or alternatively aggravated by the Veteran's service connected TBI and/or service connected right eye disability, as there is no medical literature or reasoning for these to occur. The examiner stated that the literature does not support this contention, nor does the veteran's history. While a sympathetic immune process has been known to occasionally occur in the contralateral eye, based on medical literature, the evidence to support this, based on current and past eye examinations, did not support a finding of such, nor suggest it. The examiner further noted that the medical literature submitted in January 2013 also did not support this contention, based on a thorough, current review of the general ophthalmology literature, and also after review by the senior ophthalmologist. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a left eye disorder. While the evidence of record shows that the Veteran has a current diagnosis of glaucoma of the left eye, the probative evidence of record demonstrates that such is not related to his service or his service-connected TBI or right eye disorder. In this regard, the Board places great probative weight on the VA examiner's opinion dated in October 2017 as it had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefi v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, no contrary medical opinion is of record. The Board notes that the Veteran has contended that his current left eye disorder is related to his service-connected TBI or right eye disorder. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's left eye disorder and any instance of his service, to include any service-connected disability, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Here, while the Veteran is competent to describe the current manifestations of his left eye disorder, the Board accords statements regarding the etiology of such disorder little probative value as the Veteran is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v, Brown, 7 Vet. App. 134, 137 (1994). In this regard; the diagnosis of left eye glaucoma requires the administration and interpretation of specialized eye testing. There is no indication that the Veteran possesses the requisite medical knowledge to perform such testing or interpret their results. Furthermore, the Veteran has offered only conclusory statements regarding the relationship between his service-connected TBI and right eye disorder and his current left eye disorder. In addition, although the Veteran submitted medical treatise evidence suggesting that blindness from glaucoma may start with an injury in the brain rather than the eye, the Board finds that this evidence is insufficient, standing alone, to support nexus as it is too general in nature and not related to the Veteran's case by a medical professional. See Timberlake v. Gober, 14 Vet. App. 122, 130 (2000) (noting that medical treatises can constitute competent probative evidence when combined with the opinion of a medical professional, but are often too generic and inconclusive to establish linkage on their own). In contrast, the VA examiners, who have medical experience, education, and training, took into consideration all the relevant facts in providing the opinions, to include the Veteran's contentions and the January 2013 medical literature submitted by the Veteran, as well as the current nature of his left eye glaucoma. Therefore, the Board accords greater probative weight to the October 2017 VA examiner's opinion, than that of the January 2013 medical literature or the Veteran's lay assertions as to etiology. In sum, the Board finds that left eye glaucoma is not shown to be causally or etiologically related to any disease, injury, or incident during service or to service- connected TBI or right eye disorder. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The Board notes, however, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for left eye glaucoma on a direct or secondary basis. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbertv. Derwinski, 1 Vet. App. 49, 53-56 (1990). Although the Board is appreciative of the Veteran's faithful and honorable service to our country, given the record before it, this claim must be denied. ORDER Entitlement to service connection for glaucoma of the left eye, to include as secondary to the service-connected TBI and/or service-connected right eye disability is denied. ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs