Citation Nr: 20070525 Decision Date: 10/29/20 Archive Date: 10/29/20 DOCKET NO. 10-23 126 DATE: October 29, 2020 ORDER Entitlement to an increased rating of 20 percent from January 31, 2006 to December 18, 2018 for bilateral ankle disabilities caused by residuals of stress fractures is granted. Entitlement to an increased rating in excess of 20 percent throughout the appeal period for bilateral ankle disabilities caused by residuals of stress fractures is denied. Entitlement to a total disability based on individual unemployability (TDIU) is denied. REMANDED Entitlement to a compensable rating for left eye mild proptosis and vitreous strands is remanded. FINDINGS OF FACT 1. Throughout the entire appeal period, the preponderance of the evidence showed malunion of the tibia and fibula with moderate disability caused by slight limitation of motion and functional impairment as a result of pain, weakness, and lack of endurance; the Veteran’s disability picture does not reach the level of marked disability warranting a higher rating. 2. The evidence of record does not establish that the Veteran’s service-connected disabilities render him unable to secure and follow a substantially gainful occupation.  CONCLUSIONS OF LAW 1. The criteria for an increased rating of 20 percent for bilateral ankle disabilities caused by residuals of stress fractures from January 31, 2006 to December 18, 2018, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5262-7274. 2. The criteria for an increased rating in excess of 20 percent for bilateral ankle disabilities caused by residuals of stress fractures (ankle disabilities) throughout the appeal period have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5262-7274. 3. The criteria for a TDIU have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 4.16.  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1986 to November 1991. These matters are on appeal to the Board of Veterans’ Appeals (Board) from a March 2008 rating decision. The claims were subsequently remanded by the Board in February 2018 and October 2019 decisions. With the exception of the Veteran’s January 2020 VA examination for his eye disability, which will be explained in detail in this decision, the Board finds the remand directives from the most recent October 2019 decision have been substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Additionally, a hearing was held by the undersigned Veterans Law Judge in October 2017; a transcript has been associated with the record. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.   In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).   Where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Therefore, the Board will only consider evidence submitted one year prior to the filing of the claim for an increased rating, rather than from the initial assignment. As the claim for increased ratings was filed on January 31, 2007, the appeal period goes back to January 31, 2006. 1. Entitlement to an increased rating in excess of 10 percent until December 18, 2018, and in excess of 20 percent thereafter for bilateral ankle disabilities caused by residuals of a stress fracture The Veteran is service-connected for residuals of bilateral stress fractures incurred in service that manifest in a bilateral ankle disability. During the appeal period, the Veteran’s bilateral ankle disability ratings were increased to 20 percent in a June 2019 rating decision based on the findings during a December 18, 2018 VA examination. As the increase did not constitute a full grant of benefits, his claims remain on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Diagnostic Code 5262 provides a 10 percent evaluation for malunion of the tibia and fibula with a slight knee or ankle disability, a 20 percent evaluation with a moderate knee or ankle disability, and a 30 percent evaluation with a marked knee or ankle disability. A 40 percent evaluation is warranted for nonunion of the tibia and fibula with loose motion that requires a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. There is no evidence of nonunion in the record. Under Diagnostic Code 5271, a 10 percent rating is assigned for moderate limitation of motion. A 20 percent rating is assigned for marked limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Words such as “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Use of terminology such as “severe” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Other potentially applicable diagnostic codes include Diagnostic Code 5270, which provides ratings for ankylosis of the ankle. Under Diagnostic Code 5270, ankylosis of the ankle in planter flexion less than 30 degrees is to be rated 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Normal range of motion for the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II (2016). As will be noted below, the Veteran is not shown to have had an astragalectomy at any time during the appeal period; likewise, the evidence does not demonstrate that the Veteran has ankylosis of his subastragalar or tarsal joint, or malunion of his os calcis or astragalus. The Board therefore finds that Diagnostic Codes 5272, 5273, and 5274 are inapplicable in this case, and therefore they will no longer be discussed in this decision. See 38 C.F.R. § 4.71a, Diagnostic Codes 5272-5274. The Veteran has undergone four VA examinations throughout the appeal period that provide varying opinions regarding his diagnoses and onset in service. In his May 2007 examination, the examiner opined that the Veteran really did not have a problem with his ankles, but rather his major problem was with his feet and his ankle pain was “referred pain” from his feet. Since that time, the Veteran has become service-connected for bilateral pes planus. Bilaterally, his ankle plantar flexion was to 55 degrees and dorsiflexion was to 15 degrees. The feet supinated to 35 degrees and pronated to 20 degrees. Repeat plantar flexion and dorsiflexion of his ankles and supination and pronation of his feet produced no indication of pain, weakness, or fatigue. He had no tenderness or swelling and no indication of laxity of the ankles medially, laterally, anteriorly or posteriorly. The assessment was normal bilateral ankles. In his May 2017 examination, his listed diagnoses were bilateral leg stress fractures. The Veteran expressed constant pain and cramping in his legs that make it difficult to work. He reported flare-ups which impair his ability to run, climb, or walk or stand for long periods of time. The examiner indicated that the stress fractures did not affect the Veteran’s range of motion of the ankles; however, a February 2018 Board decision found this finding to be inconsistent with the other evidence of record, and, thus, found the examination inadequate. In his December 2018 examination, the Veteran’s listed diagnoses were bilateral stress fractures and bilateral tendonitis. He stated the condition of his right ankle had worsened. He experienced stiffness, burning, throbbing, cracking, and popping. His flare-ups occurred with job duties and caused a functional loss in that he was forced to change jobs due to the pain. For his right ankle, his dorsiflexion was to 15 degrees and his plantar flexion was to 25 degrees. The loss of range of motion contributed to a functional loss due to his limited ability to bend at the ankle. Pain was noted with both dorsiflexion and plantar flexion, which caused a functional loss. There was objective evidence of localized tenderness at the lateral ankle that was reflective of the ankle condition. There was also evidence of pain with weight bearing and crepitus. Pain, fatigue, and weakness caused a functional loss after repetitive use testing with plantar flexion to 20 degrees and dorsiflexion to 15 degrees. For his left ankle, his dorsiflexion was to 15 degrees and his plantar flexion was to 30 degrees. The examiner indicated the loss of range of motion did not contribute to a functional loss, though pain was noted with both dorsiflexion and plantar flexion. There was objective evidence of localized tenderness at the lateral ankle that was reflective of his ankle condition, and evidence of pain with weight bearing and crepitus. There was no additional loss of function or range of motion after repetitive use testing, yet pain, fatigue, and weakness were noted. Bilaterally, the Veteran was not examined immediately after repetitive use over time or during a flare-up; however, the examiner opined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and flare-ups. The examiner was unable to describe the functional loss in terms of range of motion, because the Veteran reported that the loss was variable depending on how strenuously the joint was used. At its worst, the Veteran could not move it at all, but there were other times where the range of motion loss was minimal. There were no contributing factors of disability, but there was a reduction in muscle strength of both ankles, and this reduction was entirely due to the Veteran’s stress fractures. He had no ankylosis and no instability. Bilateral shin splints were indicated; the listed current symptoms for both his shin splints and stress fractures were pain with activity and weight-bearing. He reported using a cane and walker occasionally and shoe inserts. He had a bilateral ankle incision measuring two centimeters in length and width. The examiner opined that the Veteran’s new diagnosis of tendonitis was due to continued strain from the disease progression of the service-connected diagnosis of bilateral residuals of stress fractures. In the October 2019 Board decision, the claims were remanded for a new VA examination clarifying the May 2007 examiner’s opinion that the Veteran’s ankle pain was due to his feet rather than his stress fractures, and also to determine if there was a muscle injury, as indicated by treatment records. In his January 2020 examinations, the Veteran was found to have no muscle injury. The examiner also opined it is at least as likely as not that the Veteran’s loss of range of motion of his ankles are residuals of his bilateral stress fractures. His diagnoses were bilateral stress fracture residuals with ankle involvement and bilateral posterior tibial tendonitis. Regarding onset, the Veteran reported spraining his ankle running in tight boots in-service, and that despite improvement his pain has persisted all these years. The pain is most marked medially in region of the posterior tibial tendon. He reported persistent pain and swelling in his right ankle which is worsening; the pain keeps him awake at night. He endorsed flare-ups that aggravate the pain when standing, walking, or running. For his right ankle, his dorsiflexion was to 15 degrees and his plantar flexion was to 40 degrees. This loss of range of motion contributes to a functional loss with decreased mobility. Pain with dorsiflexion and plantar flexion was noted but did not cause functional loss. There was objective evidence of localized tenderness of moderate severity attributed to posterior tibial tendonitis. There was evidence of pain with weight-bearing and crepitus. He was not examined immediately after repetitive use over time or during a flare-up; however, the examiner indicated the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner found that pain, weakness, and lack of endurance caused a functional loss after repetitive use over time, with dorsiflexion at 15 degrees and plantar flexion at 40 degrees. Contributing factors to his right ankle disability included disturbance of locomotion and decreased mobility. For his left ankle, his range of motion was normal. Pain was noted with dorsiflexion and plantar flexion but did not cause functional loss. There was objective evidence of localized tenderness or pain on palpation around the ankle mortise that was described as mild and attributed to the posterior tibial tendonitis. There was evidence of pain with weight-bearing and crepitus. The examiner opined that the Veteran experienced no additional limited functional ability or range of motion with repeated use over time or during a flare-up. There were no contributing factors to his left ankle disability. Bilaterally, the Veteran performed repetitive-use testing after three repetitions with no additional loss of function or range of motion. There was no reduction in muscle strength, no ankylosis, and no instability. Shin splints were not indicated. Regarding his stress fractures, no current symptoms were indicated. No scars were indicated. No assistive devices were indicated. The examiner opined that the posterior tibial tendonitis and service-connected residuals due to stress fractures were completely different entities. The Veteran’s treatment records reflect diagnoses of stress fracture residuals, shin splints, and tendonitis. Although his records are replete with complaints of pain, there is little documentation of ranges of motion. He has used assistive devices such as ankle braces, a cane, and shoe inserts for several years. In a May 2007 record, he was noted to have weak dorsiflexion of the ankles, normal muscle strength, a pronated gait, and pain with palpation medial to the right tibia along the tibialis anterior muscle attachment and posterior tibial tendon. The same findings were noted in a February 2009 treatment record and a May 2010 orthotics prosthetics consultation. In his October 2017 hearing, the Veteran asserted his ankle disabilities were worsening with age. The examiner felt that his May 2017 examination did not address his level of pain and the way it limited his range of motion. He reported flare-ups as unbearable cramping. The Veteran also explained that the pain in his feet and ankles forced him to switch jobs from a laborer to a truck driver. Despite inconsistencies throughout the examinations, the record is fairly consistent regarding the severity of the Veteran’s ankle disabilities. There is some evidence of moderately limited range of motion throughout the appeal period; most significantly, the functional impairment from pain is reasonably evident throughout the appeal period. For example, the Veteran has endorsed using ankle braces and a cane since at least as early as June 2007. Objective evidence of pain with palpation is clear as early as May 2007. While the 2007 VA examination recorded normal ankles, a May 2007 treatment record reflects weak dorsiflexion of the ankles. Finally, the evidence shows the Veteran switched job fields due to his inability to stand for long periods of time, which is telling of functional impairment. Altogether, the evidence shows a malunion with moderate ankle disability earlier than December 19, 2018. As the complaints of pain and functional impairment go back to the date of claim, the Board finds the Veteran is entitled to a 20 percent rating as of January 31, 2006. A higher rating is not warranted as the evidence does not exhibit a more severe “marked” disability. The Veteran’s range of motion is only slightly limited; thus, the impairment due to pain, weakness, and lack of endurance more closely approximates a moderate ankle disability. 2. Entitlement to a TDIU In order to establish a TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The United States Court of Appeals for Veterans Claims (Court) has held the phrase “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 has two components; one economic and the other non-economic. Ray v. Wilkie, 31 Vet. App. 58, 73-74 (2019).  The economic component contemplates an occupation earning more than marginal income, outside of a protected environment, as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component contemplates the veteran’s ability to follow and secure employment. In this respect, due consideration must be given to their history, education, skill and training; physical ability, both exertional and non-exertional, to perform the types of activities (e.g. sedentary, light, medium, heavy or very heavy) required by the occupation at issue; and mental ability to perform the activities required by the occupation at issue. Given sedentary is defined as “doing or requiring much sitting” the Board finds that sedentary employment is a job where the worker primarily sits down. MERRIAM-WEBSTER’S COLLEGEIATE DICTIONARY 1123 (11th ed.) (2003).  In this context, appropriate factors for consideration are the veteran’s employment history, educational and vocational attainment and any other factors bearing on the issue.  38 C.F.R. §§ 3.341, 4.16. However, a veteran’s age or the impairment caused by nonservice-connected disabilities may not be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19.  As a preliminary matter, for TDIU consideration the veteran must meet the disability rating percentage threshold.  38 U.S.C. § 1155; 38 C.F.R. § 4.16(a), (b). If a veteran is service connected for only one disability, that disability must be rated at 60 percent disabling or more.  38 C.F.R. §§ 4.16 (a), 4.25.  If a veteran is service-connected for two or more disabilities, at least one of the disabilities must be rated at 40 percent disabling or more and the additional service-connected disabilities must bring the combined disability rating to 70 percent or more. Id. Here, the Veteran met the schedular criteria as of December 19, 2018. In his VA Form 21-8940, the Veteran claimed that his “legs and feet” kept him from working. He is service connected for the following: bilateral pes planus with plantar fasciitis (50 percent); bilateral ankle disabilities (20 percent each); and mild proptosis and vitreous strands of the left eye (0 percent). The Veteran previously applied for Social Security disability benefits in 2008; he asserted he was disabled because of seizures, foot and leg problems, hypertension, ulcers, and depression. It was determined that his conditions were not severe enough to keep him from working and his claim was denied. The Veteran filed for a TDIU in January 2007, and his employment circumstances have changed over time. In January 2007 correspondence, he explained he was unable to work because he could only stand for a limited amount of time and cannot wear steel toe boots, which precludes his ability to do the job for which he is qualified (construction). In May 2007, he reported he lost his job due to his feet. In April 2008 correspondence, he stated he was no longer able to work. In January 2008, he reported wearing ankle/foot braces which helped his conditions, and that he was employed driving a water truck. However, a February 2008 record reflects the Veteran was looking for a job. In June 2009, he reported being employed loading ships with rail cars. In January 2010, he reported being employed. In his August 2017 VA Form 21-8940, he reported that he was working 40 hours a week at a trucking business as a driver. An August 2017 medical record states the Veteran is currently working, is able to work, and wishes to work. A development letter was sent in December 2019 requesting additional employment information; no response was received. In his hearing, the Veteran described the difficulty working with his ankle, feet, and eye disabilities. As a truck driver, articulating the peddles is difficult on his ankles and feet. He cannot drive at night due to his eye disability which impacts the hours he can work and the amount of money he makes. He also explained that he is currently working out of necessity to support his family. Regarding his job field change in approximately 2007, he explained that a doctor recommended he switch jobs to stay off his feet. He underwent vocational rehabilitation and subsequently became a truck driver. In each of his VA examinations for his eye, no functional impact was indicated. For his ankle and feet disabilities, the examiners opined the Veteran is very limited in running, prolonged walking or standing, and in high impact activities. The Veteran is not eligible for a TDIU because the evidence shows he is not, in fact, unemployed. The Board acknowledges the Veteran’s hearing testimony that he is only working out of necessity and that his disabilities greatly impact his ability to work. However, the evidence shows he has worked as a truck driver for a fair amount of time without interruption. While working fewer hours due to his inability to drive at night certainly impacts his ability to make more money, the amount he currently makes is more than marginal income, and the most recent evidence indicates he is still able to work 40-50 hours a week. In sum, although the evidence shows that the Veteran’s service-connected disabilities make working difficult, TDIU is only granted upon evidence of actual unemployability, and, thus, his claim must be denied. REASONS FOR REMAND 3. Entitlement to a compensable rating for left eye mild proptosis and vitreous strands The Veteran has a noncompensable rating for his left eye disability. While the claim on appeal is one of increased rating, the Board notes the details regarding onset and diagnosis have varied throughout the appeal period. The Veteran has undergone four VA examinations throughout the appeal period. In his May 2007 examination, although no records were reviewed, the examiner notes a December 1987 motor vehicle accident with left eyelid trauma. The Veteran was hospitalized for three weeks and he has complained of a tearing, watery left eye since the accident. Notably, the service treatment records (STRs) indicate a right eye injury only following the accident. He had normal visual acuity and two small healed lower eyelid skin lacerations were noted, as well as left lower lid retraction of two millimeters. He had full visual field in both eyes. There were no ocular sequelae from the accident. The examiner indicated the left lower eyelid retraction with dry eye symptoms of watery left eye may be related to the accident, but there were no medical records available for review. In his April 2017 examination, his diagnosis was vitreous floaters in both eyes. The Veteran reported that in 1987 he was in a car accident and glass fragments got into his left eye, and he also injured his right eye in 2011 when a crowbar hit him in the eye. He explained that his vision has been worsening, and that his left eye jumps a lot and he gets headaches behind the left eye. He stated he has undergone surgery and was given eye drops. Again, he had normal corrected distance visual acuity. He had no diplopia and normal visual field. Occasional vitreous floaters were present bilaterally. The examiner indicated there was no scarring and no incapacitating episodes. In the rationale, the examiner explained that there are vitreous floaters present in both eyes. There was no evidence of vitreous strands but there are occasional floaters. The Veteran had prominent eyes but no proptosis (for which he is service-connected). In the October 2017 hearing, the Veteran explained his vision is worse in the left eye, and that he is unable to drive at night due to “spots” in his sight, which also affect him during the day and requires him to wear dark shade lenses in order to see. In the February 2018 Board decision, the claim was remanded for another VA examination. The examiner was directed to perform visual field testing and discuss the Veteran’s reports of seeing spots, having to wear dark lenses during the day, and being unable to drive at night. In his December 2018 examination, his diagnoses were bilateral vitreous floaters, bilateral trace cortical cataracts, and left eye proptosis. The examination was conducted by the April 2017 examiner. The Veteran complained of bright lights bothering him and blurry vision in his eye. He had normal corrected distance visual acuity for VA purposes. Occasional vitreous floaters were present in the right eye, few vitreous floaters present in the left. There was no visual field defect, and testing was not conducted. Slight proptosis of the left eye was noted. The examiner explained that cortical cataracts could be secondary to aging and have nothing to do with proptosis or vitreous strands. The vitreous floaters did not appear related to the service-connected problem because the floaters are present in both eyes and are most likely age-related. His left eye proptosis causes no symptoms. The examiner believed the left eye vitreous strands had resolved, and while they could be the cause of the bilateral vitreous floaters, since they were in both eyes it was not likely. The Veteran’s service-connected diagnoses of vitreous strands in the left anterior chamber had completely resolved. In the October 2019 Board decision, the claim was remanded for another VA examination for visual field testing, as it was not conducted in the December 2018 examination. The remand also directed the examiner to opine whether it was at least as likely as not that the Veteran’s cataracts, vitreous floaters, and other eye disabilities began during or were caused by service. The decision noted that the Veteran is service-connected for left proptosis and vitreous strands; however, records indicate he injured his right eye in the 1987 car accident rather than his left. He was treated for bilateral viral keratitis in November 1989. The examiner was also directed to address the Veteran’s report of “spots” in his vision. In his January 2020 examination, the same examiner who conducted the previous two examinations opined it is less likely than not that the Veteran’s left eye diagnoses are related to service. He stated that on reviewing the claims file, the Veteran’s injury was to the right eye and not the left. The examiner also opined it was less likely than not that the “spots” the Veteran complains of are from his vitreous floaters. The examiner explained that the Veteran only complains about floaters when he sees headlights. He did not complain about floaters at other times, such as when looking at light colored walls or in the sunlight. These would normally be described as a hair, spider web, or flies. The Veteran had the same diagnoses as the previous examination, and his corrected distance visual acuity was again normal for VA purposes. Visual field testing was once again not conducted. The examiner opined that the Veteran’s condition appeared unchanged. There was slight proptosis in the left eye that may be physiologic in nature; the difference between the two eyes was about one millimeter. The examiner’s statement that the Veteran only complains of floaters at night is inconsistent with the record. For example, in the hearing the Veteran endorsed seeing spots “everywhere,” even while at the hearing. He stated he must keep dark shades on because the sunlight irritates his eye. Thus, although the Board regrets further delay, the claim must be remanded for an adequate VA examination that accurately considers the Veteran’s testimony and includes visual field testing. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value). The matter is REMANDED for the following action: Schedule the Veteran for another VA examination for his left eye disability. Visual field defects have been indicated by the Veteran; thus, visual field testing MUST be conducted. The entire claims file must be reviewed and the Veteran’s testimony must be considered and addressed – to include his hearing testimony that he experiences “spots” in his vision both day and night, requiring him to wear dark shades during the day and abstain from driving at night. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Carroll, 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.