Citation Nr: 18127411 Decision Date: 08/20/18 Archive Date: 08/17/18 DOCKET NO. 15-04 027 DATE: August 20, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a disorder manifested by multiple joint pain is denied. Entitlement to service connection for an eye disorder, claimed as lack of depth perception, is denied. REMANDED Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure in Thailand is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for residuals of a head injury, to include traumatic brain injury (TBI) is remanded. Entitlement to service connection for a disorder manifested by vertigo is remanded. FINDINGS OF FACT 1. Any current hearing loss is not shown to be of service origin. 2. Any current tinnitus is not shown to be of service origin. 3. Any left shoulder disorder is not shown to be of service origin. 4. Any right shoulder disorder is not shown to be of service origin. 5. Any low back disorder is not shown to be of service origin. 6. Any disorder manifested by multiple joint pain is not shown to be of service origin. 7. The Veteran has not been diagnosed with an eye condition other than refractive errors, and there is no evidence of aggravation or an additional disability of the eyes superimposed on such refractive that is related to military service. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 2. The criteria for service connection for tinnitus are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for a left shoulder disorder are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. The criteria for service connection for a right shoulder disorder are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 5. The criteria for service connection for a low back disorder are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 6. The criteria for service connection for a disorder manifested by multiple joint pain are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 7. The criteria for service connection for an eye disorder, claimed as decreased depth perception, are not met. 38 U.S.C. 38 U.S.C. §§ 1101, 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Air Force from February 1972 to February 1976. His military occupational specialty was munitions maintenance specialist, being the civilian equivalent of explosive operator. He had one year and three months of foreign or sea service. His military decorations included the National Defense Service Medal. He was not given any awards or decorations indicative of combat service. A March 1995 correction to his DD 214 reflects that he was awarded the Vietnam Service Medal. Historically, the Veteran, via his representative, in November 1989 appealed a June 1989 rating decision which denied service connection for bilateral carpal tunnel syndrome (as being unrelated to a inservice excision of a left wrist ganglion cyst), a skin condition, and hepatitis but granted service connection for residuals of excision of a ganglion cyst of the left wrist, which was assigned an initial noncompensable disability rating. A Statement of the Case was issued on November 27, 1989. However, an appeal was never perfected by the filing of a Substantive Appeal, VA Form 9 or equivalent. The Veteran testified in support of his claims before the undersigned Veterans Law Judge (VLJ) at a July 2015 videoconference and a transcript thereof is on file. This appeal was processed using the Veteran's Benefits Management System (VBMS) and, in addition there is a Virtual VA paperless claims electronic file (now described as Legacy Content Manager Documents). Accordingly, any future consideration of this appeal should take into consideration the existence of these electronic records. Principles of Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Refractive errors of the eye are not considered diseases or injuries for which service connection is available. 38 C.F.R. §§ 3.303(c), 4.9. Certain chronic diseases, which include arthritis, organic diseases of the nervous system, including a sensorineural hearing loss and tinnitus; and diseases of the endocrine system, including diabetes mellitus, that are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309 Whether lay evidence is competent and sufficient in a particular case is an issue of fact. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Background On examination for service entrance in September 1971 it was noted that the Veteran had esotropia and strabismus. Audiometric testing revealed the Veteran’s hearing acuity, in decibels, at certain frequencies was as shown below: Hertz→ Decibels↓ 500 1,000 2,000 3,000 4,000 Right Ear 15 15 5 Not Tested 15 Left Ear 15 5 5 Not Tested 10 The summary of defects reported “alt” strabismus with heterophoria. In an adjunct medical history questionnaire it was reported that the Veteran wore glasses. He had not attempted suicide and had not worn a brace of back support. He reported having been told in the past that he had heterophoria. In March 1972 the Veteran’s left foot was swollen due to having blisters. In October 1972 the Veteran fell off of a trailer and bumped the left side of his head inferior to the left ear. He claimed to be dizzy and vision in his left eye was blurred. After a physical examination the impression was that he did not have any serious disease. A January 1973 service personnel record shows that the Veteran had had duty at Korat, Royal Thailand Air Force Base during which he received, inspected, assembled, and load various munitions. In October 1973 the Veteran reported having had dizzy spells after donating blood. He was to return to the clinic if the problem persisted. In December 1973 the Veteran was seen at an optometry clinic. It was noted that he wore glasses, and he complained of his eyes being sore and having headaches. In February 1974 it was noted that the Veteran had a ganglion cyst of the left wrist and a lipoma of the left side of his back. In March 1974 the Veteran had a ganglion of his left wrist, which he had had for about 1 ½ years. There was a 1 cm. firm cystic lesion of the dorsal aspect of the left wrist, overlying the base of the 4th metacarpal. The cystic lesion was excised. A left wrist X-ray was normal. In August 1974 the Veteran was issued prescription lenses due to esotropia and hyperopia. The Veteran has submitted a January 1975 letter from a military optometrist of the Griffis Hospital U.S. Air Force Base which states that the Veteran was seen and found to have normal acuity in both eyes. However, he did have an alternating esoptropia which prevented binocular vision. He would therefore be unable to pass standard depth perception tests. This condition was permanent but not progressive and would not prevent him from safely operating a motor vehicle. Audiometric testing in February 1975 revealed the Veteran’s hearing acuity, in decibels, at certain frequencies was as shown below: Hertz→ Decibels↓ 500 1,000 2,000 3,000 4,000 Right Ear 15 5 0 0 5 Left Ear 5 0 0 0 10 The January 1976 examination for service separation revealed a 3 cms. horizontal surgical scar on the posterior aspect of the left wrist. Audiometric testing revealed the Veteran’s hearing acuity, in decibels, at certain frequencies was as shown below: Hertz→ Decibels↓ 500 1,000 2,000 3,000 4,000 Right Ear 10 5 0 0 15 Left Ear 5 0 0 0 5 The service separation examination noted that the Veteran had had a benign growth removed from his left wrist in 1974. He wore glasses for defective visual acuity and being cross-eyed for the last 2 ½ years. He had had dizziness when stationed in Guam in 1974 after donating blood, which had not required any treatment and there had been no recurrence. He had a fatty tissue cyst of the middle of the low back which could be electively removed but he had not sought treatment. He had had an episode of a loss of consciousness for a duration of 45 minutes but no treatment had been required and there had been no recurrence. In an adjunct medical history questionnaire the Veteran reported that he wore glasses and had vision in both eyes. He had not worn a back brace or back support. He had not attempted suicide. He reported having or having had dizziness or fainting spells. He reported not having or having had swollen or painful joints, eye trouble, hearing loss, head injury, jaundice or hepatitis, broken bones; arthritis, rheumatism or bursitis; lameness, painful or “trick” shoulder or elbow, recurrent back pain, trick or locked knee, foot trouble, frequent trouble sleeping, depression or excessive worrying, nervous trouble of any sort or periods of unconsciousness. The Veteran applied for VA education benefits in 1976. In a handwritten note to VA Form 21-4142, Authorization for Release of Information, in June 1989 the Veteran reported that due to his finances he had not seen a doctor after leaving military service until he began receiving VA treatment at White River Junction. VA outpatient treatment (VAOPT) records show that in June 1988 the Veteran reported that his left shoulder was still bothersome. In August 1988 he was noted to have a significant history of alcohol intake, ingesting one case of beer per day four years ago, and currently averaging one six-pack of beer daily. The impression was possible alcohol related disease. In December 1988 he was noted to have a history of bilateral forearm and shoulder pain and tingling. Also in December 1988 it was noted that the Veteran was an appliance repairman, and he complained of having numbness and weakness for several months, which was improved with the use of wrist splints for the past week. VAOPT records show that in January 1989 the Veteran was issued bilateral wrist braces in December 1988. He complained of numbness and tingling. He stated that his shoulders had improved. He described numbness and tingling along the median nerve distribution, bilaterally. Tinel’s sign was positive, bilaterally, as to the ulnar nerve. He complained of increased shoulder weakness bilaterally. The assessment was that he had signs of carpal tunnel syndrome (CTS) and ulnar nerve entrapment, bilaterally. Undated electrodiagnostic testing was consistent with entrapment of the ulnar nerve at the right cubital tunnel and entrapment of the median nerve at the right carpal tunnel. Also in January 1989 there was an assessment of questionable “ALD” and questionable “chronic hepatitis.” In May 1989 the Veteran filed a claim for service connection for hepatitis, a skin condition, and disability of both wrists, alleging that he had had all of these since his military service, and was being treated at a VA hospitalization in White River Junction, Vermont. In conjunction with the Veteran’s February 2013 claim for service connection for the disabilities herein at issue he submitted VA Form 21-4138, Statement in Support of Claim, in which he stated that during service he foot caught in a hole, causing him for fall off of a bomb transport flatbed truck and hit his head on the truck bed and on the pavement below. He lost consciousness and upon awakening he was dizzy and disoriented. He was taken to an emergency room but the night shift airman on duty instructed him to return to work. He believed that this injury had caused his tinnitus in his left ear, vertigo, and loss of depth perception. When he had been transferred to Griffis, Air Force Base in Rome, New York, he had not been able to pass his driver’s license test because of a loss of depth perception. The Veteran also stated that his shoulders had been painful for years and he believed that it was due to his strenuous work during service, and this work had caused his low back disorder and pain of multiple joints. In February 2014 a VA medical opinion was obtained. It was noted that the Veteran had been in the Air Force from February 1972 to February 1976 as a munitions maintenance specialist. The following hearing evaluations were found in his STRs (contained in VBMS): 09/22/1971: Hearing within normal limits 500-4000 Hz (no 3000, 6000 Hz) 06/1972: Hearing within normal limits 500-4000 Hz (no 3000, 6000 Hz) 02/14/(no year given): Within normal limits 500-6000 Hz. 01/12/1976 (Separation): Within normal limits 500-6000 Hz. It was noted that the Institute of Medicine (IOM) (2006) had reported that, based on current understanding of auditory physiology, hearing loss from noise injuries occurred immediately following exposure. The IOM stated there was no scientific basis to conclude that permanent hearing loss directly attributable to noise exposure would develop long after such noise exposure. Therefore, there was no scientific basis on which to conclude that the current hearing loss was caused by or the result of military service, to include military noise exposure. There was not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss could develop much later in one's lifetime, long after the cessation of that noise exposure. Although the definitive studies to address this issue had not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it was unlikely that such delayed effects occur. The medical opinion further stated that in this case, the records showed no hearing loss or significant changes in hearing thresholds greater than normal measurement variability during military service. There was no record of complaint or treatment of the claimed condition in the service records. The IOM stated there was insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure would develop long after noise exposure. The IOM panel concluded that based on their current understanding of auditory physiology a prolonged delay in the onset of noise-induced hearing loss was "unlikely." Based on the objective evidence, i.e., the service audiograms, a VA audiologist concluded there was no evidence on which to conclude that the Veteran's current hearing loss or complaint of tinnitus was caused by or a result of the Veteran's military service, including noise exposure. However, the Board notes that the reference in the February 2014 medical opinion to there having been four (4) audiometric examinations during service is apparently incorrect. The reference to there having been audiometric testing in June 1972 is incorrect; rather, the “Reference Audiogram” from which this data is obtain merely reflects that the Veteran was assigned to a duty in which he was exposed to noise in June 1972 but the actual audiometric results were merely carried over from the audiometric testing at service entrance in September 1971. Also, the reference to an audiometric test results from “02/14/(no year given)” comes from Hearing Conservation Data which indicates the day and month, i.e., the 12th of February, without specifying the year but at the bottom it is shown that the testing was done in February 1975. Thus, the results of only three, and not four, audiometric tests were conducted during service, i.e., at service entrance in September 1971, in February 1975, and at the service discharge examination in January 1976. In the Veteran’s June 2014 Notice of Disagreement (NOD) it was stated that during service he had been stationed at Korat Royal Thailand Air Force Base for six months, preparing and loading bombs to be used in missions over Vietnam, as well as disarming bombs and munitions not expended over Vietnam. Planes and munitions returning from Vietnam were suspected of being contaminated with herbicides and there was documented use of herbicides at Korat. He had been in charge of inspecting and handling chemical munitions, including mustard gas and nerve agents while stationed at Griffis AFB in Rome, New York, and the destruction of all forms of munitions at what was now Fort Drum, New York. He was now being treated for type II diabetes mellitus by VA. In the June 2014 NOD it was stated that the Veteran had been treated for PTSD issues at the “South Burling Veterans Center” in the early 1980s, and had been seen at the VA Medical Center in White River Junction, Vermont, for the same issues. Of record is a “Memorandum for Record – Herbicide Use in Thailand” which states that: The Compensation Service has reviewed a listing of herbicide use and test sites outside Vietnam provided to our office by the Department of Defense (DoD). This list contains 71 sites within the U.S. and in foreign countries where tactical herbicides, such as Agent Orange, were used, tested, or stored. Testing and evaluations of these tactical herbicides were conducted by or under the direction of the U.S. Army Chemical Corps, Fort Detrick, Maryland. The list does not contain names of individuals. Additionally, it does not contain any references to routine base maintenance activities such as range management, brush clearing, weed killing, etc., because these vegetation control activities were conducted by the Base Civil Engineer and involved the use of commercial herbicides approved by the Armed Forces Pest Control Board. The application of commercial herbicides on military installations was conducted by certified applicators. DoD has advised us that commercial herbicides were routinely purchased by the Base Civil Engineer under federal guidelines and that records of these procurements were generally kept no longer than two years. We have also reviewed a series of official DoD monographs describing in detail the use, testing, and storage of herbicides at various foreign and domestic locations. In addition, the Project CHECO Southeast Asia Report: Base Defense in Thailand, produced during the Vietnam era, has been reviewed. Regarding your Veteran claimant with Thailand service, the DoD list indicates only that limited testing of tactical herbicides was conducted in Thailand from 2 April through 8 September 1964. Specifically, the location identified was the Pranburi Military Reservation associated with the Replacement Training Center of the Royal Thai Army, near Pranburi, Thailand. The Report of these tests noted that 5 civilian and 5 military personnel from Fort Detrick, Maryland conducted the spray operations and subsequent research. This location was not near any U.S. military installation or Royal Thai Air Force Base. Tactical herbicides, such as Agent Orange, were used and stored in Vietnam, not Thailand. We received a letter from the Department of the Air Force stating that, other than the 1964 tests on the Pranburi Military Reservation, there are no records of tactical herbicide storage or use in Thailand. There are records indicating that commercial herbicides were frequently used for vegetation control within the perimeters of air bases during the Vietnam era, but all such use required approval of both the Armed Forces Pest Control Board and the Base Civil Engineer. In Vietnam, tactical herbicides were aerially applied by UC-123 aircraft in Operation RANCH HAND or by helicopters under the control of the U.S. Army Chemical Corps. Base Civil Engineers were not permitted to purchase or apply tactical herbicides. There are no records of tactical herbicide spraying by RANCH HAND or Army Chemical Corps aircraft in Thailand after 1964, and RANCH HAND aircraft that sprayed herbicides in Vietnam were stationed in Vietnam, not in Thailand. However, there are records indicating that modified RANCH HAND aircraft flew 17 insecticide missions in Thailand from 30 August through 16 September 1963 and from 14 -17 October 1966. The 1966 missions involved the spraying of malathion insecticide for the "control of malaria carrying mosquitoes." These facts are not sufficient to establish tactical herbicide exposure for any Veteran based solely on service in Thailand. While the Thailand CHECO Report does not report the use of tactical herbicides on allied bases in Thailand, it does indicate sporadic use of non-tactical (commercial) herbicides within fenced perimeters. Therefore, if a Veteran's MOS (military occupational specialty) or unit is one that regularly had contact with the base perimeter, there was a greater likelihood of exposure to commercial pesticides, including herbicides. Security police units were known to have walked the perimeters, especially dog handlers. However, as noted above, there are no records to show that the same tactical herbicides used in Vietnam were used in Thailand. Please consider this information when you evaluate the Veteran's claim. If the Veteran's claim is based on servicing or working on aircraft that flew bombing missions over Vietnam, please be advised that there is no presumption of "secondary exposure" based on being near or working on aircraft that flew over Vietnam or handling equipment once used in Vietnam. Aerial spraying of tactical herbicides in Vietnam did not occur everywhere, and it is inaccurate to think that herbicides covered every aircraft and piece of equipment associated with Vietnam. Additionally, the high-altitude jet aircraft stationed in Thailand generally flew far above the low and slow flying UC-123 aircraft that sprayed tactical herbicides over Vietnam during Operation RANCH HAND. Also, there are no studies that we are aware of showing harmful health effects for any such secondary or remote herbicide contact that may have occurred. If the Veteran's claim is based on general herbicide use within the base, such as small-scale brush or weed clearing activity along the flight line or around living quarters, there are no records of such activity involving tactical herbicides, only the commercial herbicides that would have been approved by the Armed Forces Pest Control Board and sprayed under the control of the Base Civil Engineer. Since 1957, the Armed Forces Pest Control Board (now the Armed Forces Pest Management Board) has routinely provided listings of all approved herbicides and other pesticides used on U.S. Military Installations worldwide. The Compensation Service cannot provide any additional evidence beyond that described above to support the Veteran's claim. Therefore, unless the claim is inherently incredible, clearly lacks merit, or there is no reasonable possibility that further VA assistance would substantiate the claim [see 38 C.F.R. 3.159(d)], regional offices should send a request to JSRRC for any information that this organization can provide to corroborate the Veteran's claimed exposure The Veteran testified in support of his claims at a July 2015 Board videoconference. As to the claim for service connection for diabetes mellitus, type II, the Veteran testified that he had been stationed for six months at the Korat Royal Thailand Air Force Base preparing and loading bomb for use in missions over Vietnam, and disarming bombs and munitions that had not been expended over Vietnam. However, he had never been in Vietnam. It was stated that the Veteran was now being treated for diabetes at the VA Medical Center in White River Junction, Vermont. While stationed in Thailand he had been assigned to Camp Friendship which was just outside the perimeter of the Korat Air Base. Maps and photographs were submitted depicting how he had to maneuver to get to work at the Korat Air Base, by passing the perimeter as many as eight times daily. As to the claims for service connection for bilateral hearing loss and tinnitus, the Veteran testified that in performing his inservice duties he had not hearing protection, including when he had to work near a flight line. As to psychiatric disability, at the 2015 videoconference the Veteran testified that he had been a nervous person upon entrance into service. The Veteran testified that he had had numerous challenges and dangers from his inservice work inspecting and handling a variety of munitions, including chemical munitions, including mustard gas and nerve agents without using any protective gear. It was reported that the Veteran was treated for PTSD at the “South Marlton” [phonetic spelling] Veterans Center in the early 1980s and had been seen for the same issues as the VA Medical Center in White River Junction, Vermont. He had last sought psychiatric treatment 4 or 5 months ago at a VA facility in White River Junction, Vermont. He also admitted that he had not been diagnosed as having PTSD. As to disorders of the left shoulder, right shoulder, low back, and a disorder manifested by multiple joint pain the Veteran testified that he believed that performing heavy manual labor had caused disabilities of each shoulder, his low back, and all of his joints. He also testified that his inservice work with munitions caused him to be in contact with various chemicals that were implicated in his having problems with his joints. As to the claims for an eye disorder, claimed as decreased depth perception; head injury residuals, including TBI; and disorder manifested by vertigo the Veteran testified that during service he had fallen, and hit his head on trailers and then also hit his head on the pavement, causing him to lose consciousness. When he regained conscious things were blurry and he was taken to an emergency room but the presiding airman asked the Veteran if his sight was returning and upon the Veteran’s replying in the positive he was instructed to return to work. A month or two later, when transferred to Griffis Air Base, he flunked an on-base Department of Motor Vehicles test and was told he had lost his depth perception. He had then seen an optometrist and a written statement from that optometrist [dated in January 1975] was submitted into the record. The Veteran testified that he still had a loss of depth perception. The Veteran also felt that the inservice fall and head injury had contributed to his vertigo. He testified that his vertigo had returned after he had hit his head about two (2) years ago. He had been diagnosed as having vertigo by VA about 2 years ago, and he had been sent for rehabilitation to “Rutland Hospital.” As to his eyes, the Veteran testified at the videoconference that in 1975 he had some problems with his vision and was diagnosed during service by “Dr. Paige (phonetic)” as having lost his depth perception. Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertin0ent to service, establishes the disease was incurred in service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Refractive errors of the eye are not considered diseases or injuries for which service connection is available. 38 C.F.R. §§ 3.303(c), 4.9. Certain chronic diseases, which include arthritis, organic diseases of the nervous system, including a sensorineural hearing loss and tinnitus; and diseases of the endocrine system, including diabetes mellitus, that are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Whether lay evidence is competent and sufficient in a particular case is an issue of fact. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). 1. Entitlement to service connection for bilateral hearing loss Initially, the Board notes that for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). “Audiometric testing measures threshold hearing levels (in decibels (dB) over a range of frequencies (in Hertz (Hz)); the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss. CURRENT MEDICAL DIAGNOSES & TREATMENT 110-11 (Stephen A. Schroeder et al. eds., 1988).” Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In Hensley v. Brown, 5 Vet. App. 155, 159 (1993) the Court stated that: [Applicable VA regulations do] not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service. . . . Therefore, when audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Id. at 159-60. The holding in Hensley was that VA may not use audiometric tests from a claimant's separation examination as a per se legal bar on proving service connection. In Hensley, inservice audiometric testing yielded elevated thresholds at some frequencies and, so, the Court found that even if audiometric testing at service separation did not meet the requirements of 38 C.F.R. § 3.385 (establishing hearing loss by VA standards) the service connection claim could not be denied solely on that basis. Rather, if there were any current hearing loss (by VA standards) it had to be determined whether shifts in auditory thresholds during service represented the onset of any current hearing loss (even if first diagnosed a number of years after service). However, the holding in Hensley, Id., places no limitation on the results of inservice audiometric tests being used by medical examiners to reach an opinion, even a negative opinion, and does not hold that VA must disregard an otherwise adequate medical opinion (even if a postservice examiner found audiometric results etiologically relevant). See Gruen v. Shinseki, No. 09-3603, slip op. (U.S. Vet. App. May 16, 2011) (nonprecedential unpublished memorandum decision); Slip Copy, 2011 WL 1837395 (Table) (Vet.App.) (noting that the Board had conceded inservice exposure to acoustic trauma and the claimant currently had a hearing loss by VA standards). More to the point, in this case the audiometric testing conducted at the time of the Veteran’s service separation examination did not, in the opinion of a VA audiologist, reflect a shift in auditory thresholds at any relevant frequency in either ear. If such testing had reflected a threshold shift indicative of hearing loss, it would have been reported. Comparing puretone threshold levels at examination for service entrance with those at service separation shows that all threshold levels either were the same or better at service discharge than at entrance into service. Accordingly, any shift in threshold levels, which in this case were for the better, could not be indicative of a hearing loss. Thus, the holding in Hensley, Id., is inapposite. In this case, no postservice audiometric testing has been conducted and, as such, a hearing loss by VA standards is not shown at any time. However, even if he had a hearing loss by VA standards, and even with consideration being given to the Veteran’s testimony of inservice exposure to acoustic trauma, and even assuming his credibility, the Board finds that February 2014 VA medical opinion to be persuasive. That opinion considered that there were no significant threshold changes during the Veteran’s military service as well as his report of inservice exposure to acoustic trauma but found it unlikely that it would have any delayed effect, i.e., cause a hearing loss after military service. Even conceding that the Veteran was exposed to acoustic trauma during service, this is not the same as having sustained the type of injury, or even a head injury, that necessarily and always causes a hearing loss. This is particularly true because at service discharge the Veteran reported that he did not have a hearing loss. In other words, even if he was exposed to acoustic trauma during service, this does not automatically mean that he developed a hearing loss thereby. The Veteran and his representative have not pointed to any such statutory or regulatory presumption to this effect, and the Board is aware of none. Moreover, the Veteran first filed a claim for VA benefits in 1976 but he has not offered any reason for not having filed a claim for service connection for hearing loss at that time or at any time prior to 2013. Additionally, the Veteran has not stated or testified that he was diagnosed with a hearing loss during service or within one year after his February 1976 service discharge. See generally Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, there is no evidence that the Veteran’s lay statements or testimony describing symptoms during service has been supported by a later diagnosis of a hearing loss by VA standards by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). While posited as lay evidence, the Veteran’s belief that the in-service noise exposure was the cause or a precursor of any current hearing loss, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent because hearing loss can have many causes and so medical expertise is necessary to resolve the question. Since, for these reasons, the preponderance of the evidence is against the claim for service connection for hearing loss, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for tinnitus As with the claim for service connection for hearing loss, there is no evidence during service of tinnitus. Even with consideration being given to the Veteran’s testimony of inservice exposure to acoustic trauma, and even assuming his credibility, the Board finds that February 2014 VA medical opinion to be persuasive. That opinion considered that there were no significant threshold changes during the Veteran’s military service as well as his report of inservice exposure to acoustic trauma but found it unlikely that it would have any delayed effect, i.e., cause tinnitus after military service. Even conceding that the Veteran was exposed to acoustic trauma during service, this is not the same as having sustained the type of injury, or even a head injury, that necessarily and always causes tinnitus. In other words, even if he was exposed to acoustic trauma during service, this does not automatically mean that he developed tinnitus thereby. The Veteran and his representative have not pointed to any such statutory or regulatory presumption to this effect, and the Board is aware of none. Moreover, the Veteran first filed a claim for VA benefits in 1976 but he has not offered any reason for not having filed a claim for service connection for tinnitus at that time or at any time prior to 2013. Additionally, the Veteran has not stated or testified that he was diagnosed with tinnitus during service or within one year after his February 1976 service discharge. See generally Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, there is no evidence that the Veteran’s lay statements or testimony describing symptoms during service has been supported by a later diagnosis of tinnitus by a medical professional, i.e., in 2011. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). While posited as lay evidence, the Veteran’s belief that the in-service noise exposure was the cause or a precursor of any current tinnitus, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent because tinnitus can have many causes and so medical expertise is necessary to resolve the question. Since, for these reasons, the preponderance of the evidence is against the claim for service connection for tinnitus, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a left shoulder disability There is no evidence of a left shoulder disability during service and the earliest evidence of a complaint relative to the Veteran’s left shoulder is in 1988, more than a decade after military service. The Veteran seeks to establish a nexus between his military service and some left shoulder disorder by alleging that any current left shoulder disorder is due either to the stresses and strains of physical labor during service or exposure to various chemicals in performing his military duties, to include herbicides, mustard gas, and nerve agents. He neither submits nor cites to any competent medical evidence in support of this hypothetical nexus. While posited as lay evidence, the Veteran’s belief that inservice physical stress or chemicals of some kind are the cause or a precursor of some left shoulder disability, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent. There is no competent evidence of record establishing a nexus between military service and any putative left shoulder disability. Thus, the preponderance of the evidence is against the claim for service connection for a left shoulder disability, and the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for a right shoulder disability There is no evidence of a right shoulder disability during service. The Veteran seeks to establish a nexus between his military service and some right shoulder disorder by alleging that any current right shoulder disorder is due either to the stresses and strains of physical labor during service or exposure to various chemicals in performing his military duties, to include herbicides, mustard gas, and nerve agents. He neither submits nor cites to any competent medical evidence in support of either hypothetical nexus. While posited as lay evidence, the Veteran’s belief that physical stress or chemicals of some kind are the cause or a precursor of some right shoulder disability, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent. There is no competent evidence of record establishing a nexus between military service and any putative right shoulder disability. Thus, the preponderance of the evidence is against the claim for service connection for a right shoulder disability, and the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 5. Entitlement to service connection for a low back disorder Although the Veteran did have a of his low back during service, there is no evidence of a low back disability during service. The Veteran seeks to establish a nexus between his military service and some low back disorder by alleging that any current low back disorder is due either to the stresses and strains of physical labor during service or exposure to various chemicals in performing his military duties, to include herbicides, mustard gas, and nerve agents. He neither submits nor cites to any competent medical evidence in support of either hypothetical nexus. While posited as lay evidence, the Veteran’s belief that physical stress or chemicals of some kind are the cause or a precursor of some low back disability, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent. There is no competent evidence of record establishing the existence of a nexus between military service and any putative low back disability. Thus, the preponderance of the evidence is against the claim for service connection for a low back disability, and the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 6. Entitlement to service connection for a disorder manifested by multiple joint pain There is no evidence of a disorder manifested by multiple joint pain during service. The Veteran seeks to establish a nexus between his military service and some disorder manifested by multiple joint pain by alleging that any current disorder manifested by multiple joint pain is due either to the stresses and strains of physical labor during service or exposure to various chemicals in performing his military duties, to include herbicides, mustard gas, and nerve agents. He neither submits nor cites to any competent medical evidence in support of either hypothetical nexus. While posited as lay evidence, the Veteran’s belief that physical stress or chemicals of some kind are the cause or a precursor of some disorder manifested by multiple joint pain, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent. There is no competent evidence of record establishing the existence of a nexus between military service and any putative disorder manifested by multiple joint pain. Thus, the preponderance of the evidence is against the claim for service connection for a disorder manifested by multiple joint pain, and the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Entitlement to service connection for an eye disorder, claimed as lack of depth perception, The Veteran is not claiming that he had a loss of visual acuity during active service or that anything during service caused a later decrease in visual acuity. Rather, the claims a loss or decrease of depth perception, and suggests that this may be due to a injury. The STRs clearly document that the Veteran had a developmental disorder or disorders of the eyes. At entrance into service he was found to have esotropia, strabismus, and heterophoria. Strabismus is deviation of the eye which cannot be overcome. Convergent strabismus is esotropia. Divergent and external strabismus are exotropia. Dorland’s Illustrated Medical Dictionary, 1587, (27th ed. 1988). Strabisumus is a deviation of the eye with the patient cannot overcome. Satterfield v. Nicholson, No. 03-1504, slip op. (U.S. Vet. App. December 8, 2005). “’Strabismus’ is a condition in which there is a deviation of the eye. The various forms of strabismus are denoted by the direction in which the eye is deviated. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY [hereinafter DORLAND'S] 1584 (28th ed.1984).” Duvall v. Shinseki, No. 06-3311, slip op. at 1, footnote 2 (U.S. Vet. App. May 3, 2011) (nonprecedential memorandum decision). Esotropia is strabismus in which there is manifest deviation of the visual axis of an eye toward that of the other eye. Satterfield v. Nicholson, No. 03-1504, slip op. (U.S. Vet. App. December 8, 2005). Heterophoria is a failure of the visual axes to remain parallel after visual fusional stimuli have been eliminated. Dorland’s Medical Dictionary, Shorter Edition, 1980, page 322. Refractive errors, including astigmatism, myopia, hyperopia, and presbyopia, are considered congenital defects. See M21-1 Part III, Subpart iv, 4.B.1.d. Generally, congenital defects are not diseases for VA compensation purposes.38 C.F.R. § 3.303(c); see also 38 C.F.R. § 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996). In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects or refractive errors of the eyes, even if visual acuity decreased in service, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for either a congenital defect or a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury that created additional disability. See VAOPGCPREC 82-90, 55 Fed.Reg. 45711 (July 18, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Thus, in the absence of some event or trauma, a refractive error is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. §§ 3.303(c), 4.9 (congenital or developmental defects, refractive error of the eye, personality disorders, and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); see also VAOPGCPREC 82-90. VA's General Counsel issued an opinion interpreting 38 C.F.R. § 3.303(c) to mean that that service connection may be granted for diseases of congenital, developmental, or familial origin if the evidence as a whole shows that manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 67-90. The VA General Counsel also has issued an opinion that a congenital defect can be subject to superimposed disease or injury, and, if superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. The Board has considered the January 1975 statement of a military optometrist that the Veteran had esotropia and that this prevented binocular vision such that he could not pass standard depth perception tests. State in other terms, the Veteran’s difficulty with depth perception stemmed from a lack of binocular vision and, in turn, this was due to his esotropia which was found on examination for entrance into service. Also in the instant case, the Veteran complained of blurred vision after an October 1972 injury. However, this affected only his visual acuity and there is there is no evidence that the Veteran's refractive errors were aggravated or subject to a superimposed disease or injury during his military service that resulted in additional disability. Service treatment records are silent with respect to any complaints of an increase in his lack of depth perception. Thus, as the Veteran's current eye disorders are considered congenital or developmental defects of the eyes and not a disease or injury within the meaning of applicable legislation relating to service connection, service connection may not be allowed. Accordingly, the Board must deny the claim as the Veteran does not meet the criteria for service connection, namely, a presently diagnosed disability within the meaning of the term "disability" for VA compensation purposes. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure in Thailand is remanded. Although it is conceded, as he testified at the videoconference, that the Veteran never set foot in Vietnam, his testimony and the maps submitted at the videoconference are to the effect that he was exposed to herbicides because he routinely passed through the perimeter of the Korat Royal Thailand Air Force Base. The Board will not at this time adjudicate this aspect of the claim for service connection for diabetes mellitus, type II, because in order to prevail it must also be shown that the Veteran now has diabetes mellitus, type II. Although the Veteran has testified that he is now receiving VA treatment for diabetes mellitus, type II, there are no actual medical records on file which reflect that he has been diagnosed as having diabetes mellitus, type II. Accordingly, the Veteran should be requested to provide as much information as possible as to all sources of treatment, including VA treatment, for diabetes mellitus, type II, since his military service and if obtained such records should be associated with the record on appeal. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. The Veteran testified that he had been a nervous person during service but has not testified or otherwise stated that he sought or received treatment for psychiatric disability during service. However, he has also testified that he had a head injury during service with a loss of consciousness, and at least implies that this could have given rise to a psychiatric disability. As to PTSD, he was not in combat and has not alleged any stressor related to hostile military or terrorist activity. Rather, he testified that he was under stress from performing his dangerous work in munitions. In any event, the Veteran testified that he had been treated at a Vet Center in the early 1980s for PTSD and later received VA treatment. However, there are no such records on file. Accordingly, the Veteran should be requested to provide as much information as possible as to all sources of treatment, including VA treatment, for psychiatric disability since his military service and if obtained such records should be associated with the record on appeal. 3. Entitlement to service connection for residuals of a head injury, to include TBI is remanded. The medical history questionnaire at service discharge reflects that the Veteran denied having had a head injury. However, on the other hand, there is a notation on the report of the service discharge examination that the Veteran had had an episode of loss of consciousness for a duration of 45 minutes, although it had not required treatment and there had been no recurrence. This notation is consistent with the Veteran’s testimony of having had a head injury during service, for which he reportedly sought but was refused treatment. 4. Entitlement to service connection for a disorder manifested by vertigo is remanded. The Board notes that the contemporaneous STRs show that in October 1973 the Veteran had an episode of vertigo which was associated with his having donated blood. However, in October 1972 he sustained a head trauma, and had dizziness. The Board also notes that the Veteran testified that he had a recurrence of vertigo after a second head injury which had occurred about two (2) years prior to the 2015 Board videoconference. In view of this, the Veteran should be requested to provide as much information as possible as to all treatment or evaluations following his second head injury (about two years prior to the 2015 Board videoconference), and if obtained such records should be associated with the record on appeal. Also, since the Veteran alleges that he has a psychiatric disorder, TBI, and vertigo, he should be afforded a psychiatric examination and a neuropsychiatric examination for the purpose of determining whether he now has a chronic acquired psychiatric disorder, to include PTSD; whether he now has residuals of a TBI of service origin; and whether he now has vertigo related to a TBI of service origin (as opposed to a TBI of postservice origin). The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide as much information as to the dates and places of evaluation or treatment, both private and VA, as to diabetes; any psychiatric disorder, including PTSD and to include at any Vet Center; residuals of a head injury, any head injury both during and after service, including TBI; and vertigo. It would be helpful if he, perhaps with the assistance of his service representative were to list, to the extent possible, the inclusive dates of treatment for each claimed disability at specific medical facilities. 2. After the foregoing records have been obtained, to the extent possible, afford the Veteran an examination to determine whether he has an acquired psychiatric disorder, to include PTSD. As to PTSD, the examiner should be instructed that the Veteran did not sustain any stressor in combat or due to hostile enemy or terrorist activity. If it is determined that the Veteran now has an acquired psychiatric disorder, the examiner should render an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder is of service origin. If it is determined that the Veteran had PTSD, the examiner must clarify the nature and extent of any acceptable PTSD stressor. The VA electronic records should be made available for review in connection with this examination. The examiner should provide a complete rationale for all conclusions reached. If the examiner feels that any requested opinion cannot be rendered without resorting to speculation, the examiner should state why this is so. Specifically, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given current medical science and the known facts), by a deficiency in the record (i.e., additional facts are required), or because the examiner does not have the needed knowledge, expertise or training. 3. After the foregoing records have been obtained, to the extent possible, the Veteran should be afforded an examination by a specialist in psychiatry, or neurology, or neurosurgery that has training and experience with TBI. The examination may be conducted by a nurse practitioner, a clinical nurse specialist, or a physician assistant, if clinically privileged to perform activities required for VA TBI examinations, and have evidence of expertise through training and demonstrated experience, may conduct the TBI examination under the close supervision of a board-certified or board-eligible physiatrist, neurologist, or psychiatrist. Following an examination of the Veteran an opinion should be rendered as to whether the Veteran now has any residuals of a TBI and, if so, the nature and extent of such residuals should be described, to include whether it is as likely as not (a 50 percent or greater probability) that any vertigo which the Veteran may now have is due to an inservice head injury, or if medically feasible due to a combination of an inservice head injury and any postservice head injury. An opinion should also be rendered as to whether the Veteran now has vertigo and, if so, whether it is as likely as not (a 50 percent or greater probability) that any vertigo which he now has is due to to an inservice head injury, or if medically feasible due to a combination of an inservice head injury and any postservice head injury. The VA electronic records should be made available for review in connection with this examination. The examiner should provide a complete rationale for all conclusions reached. If the examiner feels that any requested opinion cannot be rendered without resorting to speculation, the examiner should state why this is so. Specifically, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given current medical science and the known facts), by a deficiency in the record (i.e., additional facts are required), or because the examiner does not have the needed knowledge, expertise or training. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs