Citation Nr: 20000056 Decision Date: 01/02/20 Archive Date: 01/02/20 DOCKET NO. 16-23 187 DATE: January 2, 2020 REMANDED Entitlement to service connection for an eye disability is remanded. REASONS FOR REMAND The Veteran had active service from May 1964 to September 1964. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which determined that new and material evidence had not been received to reopen a claim for service connection for keratoconus in the left eye and denied a claim for a left eye injury. In a September 2017 decision, the Board found that new and material evidence had been received to reopen the Veteran’s claim for service connection for keratoconus in the left eye. The Board also expanded the scope of the Veteran’s claims to a claim for entitlement to a left eye disability, however diagnosed. Ultimately, the Board remanded the claim for the RO to obtain outstanding treatment records and to obtain a VA examination with an appropriate clinician. Following this development, the RO issued a January 2019 Supplemental Statement of the Case denying service connection for an eye disability. The matter now returns to the Board. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). Entitlement to service connection for an eye disability. The Veteran contends that he is entitled to service connection for an eye disability. More specifically, he claims that he was diagnosed with keratoconus in 1968 and that this disability had its onset after a rock hit his left eye during a training exercise in August 1964. The Board acknowledges that, as set forth in the Board’s September 2017 remand directives, the RO obtained the Veteran’s outstanding VA treatment records, took appropriate steps to request additional treatment records from the Veteran, and afforded the Veteran with a December 2018 VA examination. Nonetheless, the Board finds that another remand is necessary for the RO to obtain an addendum medical opinion. See Stegall v. West, 11 Vet. App. 268 (1998). In the Board’s September 2017 remand directives, the Board instructed the VA examiner to opine as to whether (a) it was at least as likely as not that any of the Veteran’s currently diagnosed ophthalmological disabilities, including keratoconus, had their onset during active service, including as due to the August 1964 injury during training, and (b) if the currently diagnosed ophthalmological disability, including keratoconus, did not have its onset during active service, was it aggravated by his August 1964 injury? In December 2018, the Veteran underwent a VA examination with a VA optometrist, who diagnosed the Veteran with keratoconus as of 1964 and a preoperative cataract in his left eye. First, the VA examiner stated that there was only one record of a vision screening just prior to service in March 1964. The VA examiner stated that it was possible that the Veteran always had keratoconus even prior to joining the service, but that he was never evaluated for a complete examination except for this brief screening in March 1964. The VA examiner opined that the Veteran’s keratoconus was not caused by the injury to the Veteran’s eye during service, citing to medical research stating that the cause of keratoconus is unknown but thought to be associated with an imbalance of enzymes within the cornea, overexposure to ultraviolet light, excess eye rubbing, a history of poorly fitted contact lenses, and chronic eye irritation. He also opined that medical literature suggests keratoconus might also be linked to genetics. The VA examiner ultimately opined that the “Veteran have a diagnosis of (a) Left eye disability to include all possible diagnoses that is at least as likely as incurred in service or existed prior to joining the [service].” In a January 2019 Request for Physical Examination, the RO asked the VA examiner to clarify the opinion from the December 2018 VA examination. In the request, the RO stated that there was an eye examination in the record from May 1964 that the VA examiner did not appear to have considered in his rationale. The RO also asked for the VA examiner to provide a rationale as to why the Veteran’s eye disabilities would or could be related to active duty service. In the first January 2019 addendum opinion, the same VA examiner stated that the eye examination conducted in May 1964 was not a comprehensive eye examination, but merely a vision screening where visual acuity was not actually reported. The VA examiner then stated that the Veteran did not have 20/20 vision in his left eye during active service and had keratoconus in his left eye. The VA examiner also opined that his cataracts were not related to service, as they were normal, age-related cataracts. Subsequently, the RO submitted to the VA examiner another Request for Physical Examination in January 2019, which asked the VA examiner to clarify the language of his opinion to state whether the Veteran did have a diagnosis of a left eye disability or did not have a diagnosis of a left eye disability. The RO also pointed out that the Veteran’s entrance examination prior to induction to service showed decreased visual acuity in the left eye and asked the VA examiner to provide a rationale for his conclusions. In the second January 2019 addendum opinion, the VA examiner clarified that the Veteran “does have a diagnosis” of keratoconus that was at least as likely as not incurred in service or existed prior to joining the service, but that it was not caused by a rock hitting the Veteran’s eye during service. The VA examiner also restated his conclusions from the prior addendum opinion. Thereafter, the RO submitted a third Request for Physical Examination in January 2019. In this request, the RO asked the VA examiner to clarify, based on a review of all the objective evidence, whether the Veteran’s disability was incurred during service or instead pre-existed his service. In response, the VA examiner issued a third addendum opinion in January 2019 which stated that the Veteran’s keratoconus most likely existed prior to joining service, but no complete eye examinations were performed during active service, so the condition was not noted when the Veteran entered service. The VA examiner reiterated his conclusion that the condition was not caused by the August 1964 injury to the Veteran’s eye and restated the research on the causes of keratoconus described above. The Board has carefully considered the medical evidence of record but finds that there are several deficiencies with the December 2018 VA examination and the three January 2019 addenda. First, the VA examiner’s explanations are internally inconsistent and were not provided to the correct standard of review. The VA examiner alternately states that the Veteran’s keratoconus pre-dated his service, was incurred during his service, or, somehow, both pre-dated his service and was incurred during his service. Moreover, when, after three requests for clarification, the examiner ultimately opined that the Veteran’s keratoconus pre-existed his service, the examiner failed to consider whether his active service aggravated the condition. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that an opinion that does not consider all raised theories of entitlement is inadequate). Furthermore, the VA examiner noted that the Veteran also had a diagnosis of a preoperative cataract in his left eye but concluded that it was not related to service because it was a normal, age-related cataract. This statement is conclusory, and the VA examiner cites no medical literature or evidence from the record to support it. See Stefl, 21 Vet. App. at 124. When VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, and in the interest of assembling clear and reliable findings, the Board must remand this claim for an addendum opinion from a different examiner that provides a sufficiently detailed rationale and considers all raised theories of entitlement. Accordingly, this matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records, as well as any relevant private treatment records, and associate them with the claims file. 2. Thereafter, provide the Veteran with an addendum opinion from an appropriate VA examiner other than the examiner who conducted the December 2018 examination. The claims file, including a copy of this remand, should be made available to the examiner, who must review it in conjunction with providing the addendum opinion and should note that review in the report. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to provide the following opinions: (a) Did the Veteran’s ophthalmological disability, including keratoconus clearly and unmistakably (undebatable) preexist the Veteran’s service? The examiner should specifically address the March 1964 service entrance examination that found the Veteran’s eyes to be normal. (b) If the examiner finds the Veteran’s ophthalmological disability did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. (c) If the examiner finds that the Veteran’s ophthalmological disability either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, to include as due to a rock hitting the Veteran in the eye during training in August 1964. The examiner must consider the Veteran’s lay statements relating to in-service and post-service symptomatology, as well as continuous symptoms in and after service, and should discuss the significance of those statements. The examiner should provide a complete rationale for any opinion provided. All opinions should be based on examination findings, historical records, and medical principles. If the examiner is unable to provide an addendum opinion without performing a physical examination of the Veteran, a new examination should be scheduled. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.