Citation Nr: 19112593 Decision Date: 02/19/19 Archive Date: 02/19/19 DOCKET NO. 11-14 682 DATE: February 19, 2019 REMANDED Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected right and left knee disabilities, is remanded. Entitlement to service connection for a bilateral eye disability, claimed as bilateral eye scratches with residual vision problems, is remanded. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1971 to June 1972. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2010 and January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified before a Veterans Law Judge in November 2014. However, the Veterans Law Judge who conducted the November 2014 hearing is no longer employed by the Board. Under 38 C.F.R. § 19.3(b), this appeal may be reassigned to another Veterans Law Judge for a decision. A transcript of the hearing has been associated with the record. In January 2015, the Board remanded this case for additional development. The Board denied the claims for entitlement to service connection for residuals of a TBI, a bilateral eye disability, and a back disability in August 2016. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims. In May 2018, the Court granted a Joint Motion for a Partial Remand filed by the representatives for both parties, vacating the Board’s decision, and remanding the claims to the Board for further proceedings consistent with the terms of the Joint Motion. 1. Entitlement to service connection for a lumbar spine disability, claimed as chronic low back pain, to include as secondary to service-connected right knee disability and left knee disability, is remanded. In August 2016, the Board relied on a January 2016 VA examiner’s negative opinion to deny the claim for service connection for a back disability. In the May 2018 Joint Motion, the parties agreed the Board did not adequately address the Veteran’s lay statements. In accordance with the Joint Motion, a remand is required to obtain a new medical opinion regarding the etiology of the Veteran’s back disability to address her lay statements and entitlement on the basis of secondary service connection. Entitlement to service connection for a bilateral eye disorder, claimed as bilateral eye scratches with residual vision problems, is remanded. In August 2016, the Board relied on a February 2016 VA examiner’s negative opinion to deny the claim for service connection for bilateral eye disorder. In the May 2018 Joint Motion, the parties agreed the opinion was inadequate because it did not address a medical record noting corneal scarring. In accordance with the Joint Motion, a remand is required to obtain a new medical opinion regarding the etiology of the Veteran’s bilateral eye disorder. 2. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. In August 2016, the Board relied on a January 2016 VA examiner’s negative opinion to deny the claim for service connection for residuals of a TBI. In the May 2018 Joint Motion, the parties agreed another medical opinion should be obtained to evaluate the assessment of a mild TBI by history and the Veteran’s lay statements about the progression of the disability. In accordance with the Joint Motion, a remand is required to obtain a medical opinion regarding the etiology of residuals of a TBI. The matters are REMANDED for the following action: 1. Obtain all VA treatment medical records not already of record. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any lumbar spine disabilities. The examiner must review the claims file and should note that review in the report. The examiner should obtain a complete history from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. The examiner must address and the February 2010 and January 2016 VA examination report. All findings should be reported in detail. The examiner should provide the following information: (a.) Diagnose all lumbar spine disabilities found. (b.) Is it at least as likely as not (50 percent or greater probability) that any lumbar spine disorder was caused by or is related to service? The examiner should specifically address the Veteran’s in-service fall in January 1972. The examiner should specifically address the Veteran’s lay statements regarding complaints of back pain due a fall in service, complaints of chronic back pain in 1985 and 1986, and any altered gait and limp. (c.) Is it at least as likely as not (50 percent or greater probability) that any lumbar spine disability is proximately due to or the result of any service-connected disabilities, to specifically include the right and left knee disabilities? The examiner should specifically address the Veteran’s lay statements regarding complaints of back pain due to a fall in service, complaints of chronic back pain in 1985 and 1986, and any altered gait and limp. (d.) Is it at least as likely as not (50 percent or greater probability) that any lumbar spine disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by any service-connected disabilities, to specifically include the right and left knee disabilities? The examiner should specifically address the Veteran’s lay statements regarding complaints of back pain due to a fall in service, complaints of chronic back pain in 1985 and 1986, and any altered gait and limp. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any bilateral eye disability. The examiner must review the claims file and should note that review in the report. All indicated tests and studies must be performed. The examiner must also take a full history from the Veteran. A complete rationale should be provided for all conclusions reached. The examiner should provide the following information: (a.) Diagnose all eye disabilities found. (b.) Is it at least as likely as not (50 percent or greater probability) that any eye disability was caused by or is related to service? The examiner should specifically address the Veteran’s contentions that she got seeds in her eyes during a training exercise and had in-service eye trouble. The examiner must address the February 2005 medical record noting “corneal stroma: FB scar” and the February 2016 VA examination report. 4. Schedule the Veteran for a VA TBI examination with one of the required specialists. The examiner must review the record and should note that review in the report. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should provide a complete rationale for any opinions provided. The examiner must address March 2010 evaluation and January 2016 VA examination reports. The examiner should provide the following information: (a.) Confirm that the examiner is one of the required specialists to conduct a TBI examination, to include physiatry, neurology, neurosurgery, and psychiatry. (b.) Diagnose all TBI or head injury residuals found. If no TBI or head injury residuals are identified, the examiner should expressly state that fact, and should reconcile that finding with a March 2010 VA evaluation of mild TBI. (c.) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified TBI or head injury residuals had their onset during active service or are related to any incident of service, including a January 1972 head trauma during service and being hit in the head with a large dictionary. The examiner should specifically address the Veteran’s contentions that she had a history of headaches, blackouts, and memory problems and concussion that were secondary to a fall in service with a 25 minute loss of consciousness. In addressing the Veteran’s contentions, the examiner should comment on the Veteran’s statements from a medical point of view. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Kass, Associate Counsel