Citation Nr: 1817861 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 16-53 506A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUE Entitlement to service connection for a visual field defect with peripheral pterygium and right optic nerve atrophy, claimed as a right eye condition. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Costello, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1962 to October 1964 with subsequent reserve service. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision of the St. Petersburg, Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction was subsequently transferred to Fargo, North Dakota. The Board notes that the Veteran did not request a hearing. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Board sincerely regrets the additional delay that will result from this remand, but it is necessary to have a complete record to decide the claim, so the Veteran is afforded every possible consideration. The Veteran contends that he injured his right eye in an automobile accident during active duty service and developed a scar over his right eye. Since his injury he reported difficulty reading and believes it is the cause of his current right eye conditions. The Veteran's September 1964 separation medical history indicated that the Veteran was involved in a motor vehicle accident in January 1964 and that he had a laceration to his forehead, though he indicated that he did not have eye trouble. A January 2006 VA ophthalmology treatment note indicated that the Veteran had difficulty seeing out of his right eye in July 2005. He was diagnosed with a right eye cataract, pterygium of the right eye, and a visual field defect of his right eye, to include a blind spot. The VA physician found that his condition may have been related to ischemia from a prior cardiac surgery. A January 2009 VA eye examination revealed that the Veteran had cataracts. The physician found that the Veteran's right eye impairment was caused by his cerebral vascular accident. A June 2011 private examination diagnosed the Veteran with a visual field defect of the right eye, pallor optic nerve, and dry eyes. The Veteran reported constant decreased vision at distance, which caused objects to appear fuzzy. He did not report a history of head or ocular injuries. He had a bypass surgery and reported current hypertension. The physician opined that the Veteran's loss of vision in the right eye was due to cataracts. Surgery was recommended, but the Veteran deferred surgery. In April 2017, the Veteran's primary care physician for over 15 years stated that the Veteran never had a cerebral vascular accident, also known as a stroke, in the past. The Veteran's December 2011 angiogram did not show any evidence for a stroke or any relationship between his cardiac condition and a stroke. In a May 2017 statement, the Veteran reported that he was involved in a motor vehicle accident during his active duty service and that his right eye was covered with a patch for several months. He reported difficulty reading since and believes his injury worsened since then to include his visual field defect of the right eye. Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i). A medical examination or medical opinion may be deemed necessary where the record contains competent medical evidence of a current diagnosed disability, establishes that the Veteran suffered an event, injury or disease in service, and indicates that the claimed disability may be associated with the established event, injury or disease in service. See Id. Based on the above, the Board finds that additional medical comment is needed as to whether the Veteran's current visual field defect with peripheral pterygium and right optic nerve atrophy is etiologically related to his active duty service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain and associate with the record copies of all clinical records of the Veteran's treatment at VA Medical Center in St. Cloud, Minnesota from May 2016. 2. After securing the appropriate medical release, obtain and associate with the record copies of all clinical records, which are not already in the record, of the Veteran's treatment at the Metropolitan Heart and Vascular Institute. The RO/AMC must make two attempts for the relevant private treatment records or make a formal finding that a second request for such records would be futile. See Pub. L. No. 112-154, § 505, 126 Stat. 1165, 1193 (2012). All development efforts should be associated with the record. 3. Schedule the Veteran for a right eye examination to determine the nature and etiology of any current right eye disabilities. Any indicated tests should be accomplished. The examiner should review the record prior to examination. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current right eye disability had its clinical onset during service or is related to any in-service disease, event, or injury. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 4. Review the development actions obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, the case should be returned to the examiner for completion of the inquiry. 5. Readjudicate the claim on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran and his representative should be provided with a supplemental statement of the case as to the issues on appeal, and afforded a reasonable period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).