Citation Nr: 20074059 Decision Date: 11/18/20 Archive Date: 11/18/20 DOCKET NO. 10-26 463 DATE: November 18, 2020 REMANDED Service connection for refractive error of the left eye, to include as secondary to arterial hypertension. Service connection for bilateral diabetic related cataracts, to include as secondary to arterial hypertension. Service connection for proliferative diabetic retinopathy of the left eye, to include as secondary to arterial hypertension. Service connection for severe diabetic retinopathy of the right eye, to include as secondary to arterial hypertension. REASONS FOR REMAND The Veteran served on active duty from July 1986 to December 1986. The case is on appeal from a December 2008 rating decision. The matter was last before the Board in November 2017. At that time, the Board denied an initial rating in excess of 30 percent prior to September 3, 2014; from January 1, 2015 to December 2, 2015; and a rating in excess of 60 percent from December 3, 2015 for coronary artery disease (CAD). The Board also remanded the issues on appeal for further development. 1. Service connection for refractive error of the left eye, as secondary to arterial hypertension. The Board finds that there was not substantial compliance with the Board’s November 2017 remand directives where the Board directed the RO to obtain a new VA medical opinion addressing whether the Veteran’s refractive error was subjected to a superimposed disease or injury. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board observed such an opinion is necessary for the adjudication of the Veteran’s claim. Upon remand, a new VA medical opinion was provided in November 2017. With regard refractive error of the left eye, the VA examiner acknowledged the Board’s remand directives by providing an opinion addressing whether the Veteran’s disability was congenital and whether it was caused or aggravated by arterial hypertension. However, the examiner did not provide an opinion addressing the whether the refractive error was subjected to a superimposed disease or injury. This was part of the basis for the Board’s last remand, so this leaves the November 2017 VA opinion inadequate. Accordingly, a new opinion is warranted. 2. Service connection for bilateral diabetic related cataracts, as secondary to arterial hypertension. The Board finds that there was not substantial compliance with the Board’s November 2017 remand directives where the Board directed the RO to obtain a new VA medical opinion addressing whether his cataracts were aggravated by arterial hypertension. A November 2017 VA medical opinion addressed the question of secondary service connection, but the rationale offered an inadequate explanation. While the examiner is not required to lay out the reason and bases for an opinion, he or she must provide enough of an explanation rather than a mere conclusion to allow the Board to make an informed decision as to what weight to assign an opinion. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012); Monzingo v Shinseki, 26 Vet. App. 97, 106 (2012). The November 2017 VA examiner only provided the following conclusion: less likely than not that cataracts were caused or aggravated by arterial hypertension, less likely than not congenital, less likely than not service-related, noted as being primarily secondary to diabetes mellitus at March 2008 compensation examination. This explanation is insufficient for the Board to make an informed decision. 3. Service connection for proliferative diabetic retinopathy of the left eye, as secondary to arterial hypertension. 4. Service connection for severe diabetic retinopathy of the right eye, as secondary to arterial hypertension. The Veteran contends his bilateral diabetic retinopathy are due to his service-connected arterial hypertension. The Veteran received a VA examination for these disabilities in November 2017 pursuant to the Board’s remand. The examiner provided the Veteran has a history of regressed proliferative diabetic retinopathy (status-post vitrectomy and pan-retinal photocoagulation) in both eyes. The examiner concluded that it is less likely than not that the diabetic retinopathy was caused by arterial hypertension; however, it is possible that arterial hypertension aggravated the condition, but it is impossible to quantify without resorting to mere speculation as diabetic retinopathy and hypertensive retinopathy results in a similar retinal appearance. Additionally, it is less likely than not congenital and less likely than not service related. The Board finds the November 2017 VA examination inadequate. This is so primarily because though the question could not be answered accurately and to do so would be speculation, the examiner nonetheless still opined in the negative. Further, there is no mention during the examination of the Veteran being diagnosed with hypertensive retinopathy, and it is unclear why the examiner mentioned this in the rationale. For these reasons, the Board finds the VA examination not wholly adequate, and a remand for a new examination warranted. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA medical records dated from February 2020. 2. Obtain new VA opinions from an appropriate clinician regarding the Veteran’s eye disabilities. The clinician should address the following: (a.) The Veteran’s left eye refractive error and whether there was an additional disability due to disease or injury superimposed upon the eye disability during service. (b.) The etiology of the Veteran’s cataracts, including whether: It is at least as likely as not (a 50 percent or greater probability) that the Veteran’s cataracts initially manifested during service or are otherwise related to service? It is at least as likely as not (a 50 percent or greater probability) that they were caused by the Veteran’s service-connected arterial hypertension? It is at least as likely as not (a 50 percent or greater probability) that they were caused or aggravated by the Veteran’s service-connected arterial hypertension? Aggravation is an increase in severity beyond the natural progress of the disease. If aggravation is found, the examiner must attempt to quantify the extent of additional disability resulting from aggravation. (c.) The etiology of the Veteran’s bilateral diabetic retinopathy, including whether: It is at least as likely as not (a 50 percent or greater probability) that the Veteran’s diabetic retinopathy initially manifested during service or are otherwise related to service? It is at least as likely as not (a 50 percent or greater probability) that it was caused or aggravated by the Veteran’s service-connected arterial hypertension? Aggravation is an increase in severity beyond the natural progress of the disease. If aggravation is found, the examiner must attempt to quantify the extent of additional disability resulting from aggravation. (d.) The examiner should also clarify whether the Veteran has any additional eye disabilities, including hypertensive retinopathy. If necessary, schedule the Veteran for an eye examination (or a telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of any additional eye disabilities. The examiner should then provide an opinion as to whether: It is at least as likely as not (a 50 percent or greater probability) that the disability had its onset during, or is otherwise related to, service? It is at least as likely as not (a 50 percent or greater probability) that it was caused or aggravated by the Veteran’s service-connected disabilities? A complete rationale must be provided for the opinion offered, and if an opinion cannot be offered without resort to mere speculation, the reason for this should be fully explained in the examination report. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Becton, 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.