Citation Nr: 20028063 Decision Date: 04/22/20 Archive Date: 04/22/20 DOCKET NO. 18-50 169A DATE: April 22, 2020 REMANDED The issue of entitlement to service connection for left eye pars planitis, to include ocular hypertension and optic neuritis post vitrectomy, is remanded. REASONS FOR REMAND The Veteran had active service from April 2008 to April 2014. The issue of entitlement to service connection for left eye pars planitis, to include ocular hypertension and optic neuritis post vitrectomy, is remanded. This matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: In May 2014, the Regional Office (RO) denied the Veteran’s claim for service connection for left eye pars planitis. The RO found that the Veteran’s ocular condition pre-existed his service and found no evidence that the Veteran’s service caused a worsening of his condition. During an April 2007 pre-service entrance examination, the Veteran was noted to have ocular hypertension, confirmed by diurnal Goldmann applanation readings. It was noted that the Veteran was evaluated by ophthalmology. Service treatment records indicate a diagnosis of pars planitis with on onset in 2010, approximately two years after service entrance. An August 2012 service treatment record notes that the Veteran was "recently diagnosed with pars planitis.” In a December 2013 eye examination, the optometrist stated that the Veteran entered service with ocular hypertension. The examiner opined that the Veteran's glaucoma and pars planitis are due to the natural progression of his pre-existing ocular hypertension. The examiner stated that he did not see any event or incident of record that occurred during service that would cause the condition to occur or exacerbate the condition. In an October 2018 letter, Dr. J.E.T., an ophthalmologist at the Wilmer Eye Institute, stated that she specializes in uveitis and other inflammatory eye disorders. She stated that the Veteran has been under her care since 2015 for his pars planitis. She stated that pars planitis is not a natural progression of ocular hypertension. However, Dr. J.E.T. opined that that evidence of record suggests that the Veteran’s history of corticosteroid treatments for his pars planitis exacerbated his ocular hypertension. Dr. J.E.T. opined that the Veteran’s pars planitis did not exist prior to his service and is not a natural progression of a preexisting condition. Generally, a Veteran is presumed in sound condition except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. § 1111; Horn v. Shinseki, 25 Vet. App. 231, 235 (2012); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The record is clear that ocular hypertension preexisted service as it was well documented when the Veteran entered service. However, the evidence also suggests that pars planitis did not preexist the Veteran’s service. THE ESSENTIAL QUESTIONS FOR THE EXAMINATION DIRECTED BELOW ARE: 1. IS THE VETERAN’S OCULAR HYPERTENSION, AS NOTED AT SERVICE ENTRY, THE SAME DISORDER AS HIS PAR PLANTIS DIAGNOSED AFTER SERVICE? 2. DID THE VETERAN’S OCULAR HYPERTENSION, AS NOTED AT SERVICE ENTRY, NATURALLY PROGRESS INTO PAR PLANTIS? 3. WAS PAR PLANTIS INCURRED IN OR AS A RESULT OF MILITARY SERVICE? Thus, the Board finds that the Veteran’s pars planitis did not preexist his service. 2. Obtain any outstanding VA medical records and associate them with the claims file. 3. Schedule the Veteran for a VA examination, in accordance with established VA examination protocols, with an appropriate VA ophthalmologist regarding the nature and etiology of the Veteran’s left eye condition. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail. THE EXAMINER MUST PROVIDE A DETAILED EXPLANATION FOR ANY OPINION RENDERED. The examiner’s attention is drawn to the following: * In the Veteran's April 2007 ROTC examination, a diagnosis of ocular hypertension is noted, which is noted as confirmed by diurnal Goldmann applanation readings. It was noted that the Veteran was evaluated by ophthalmology. * There is no record of a diagnosis of pars planitis prior to service. * Service treatment records indicate treatment with Combigan, Cosopt, Dorzolamide Hydrochloride, Methotrexate, and Pilocarpine. * Service treatment records indicate a diagnosis of pars planitis with on onset in 2010. * An August 2012 service treatment record notes that the Veteran was "recently diagnosed with pars planitis.” * Vitrectomy was performed in 2013. * In a December 2013 eye examination, the optometrist stated that the Veteran entered service with ocular hypertension. The examiner opined that the Veteran's glaucoma and pars planitis are due to the natural progression of his pre-existing ocular hypertension. The examiner stated that he did not see any event or incident that occurred during service that would cause the condition to occur or exacerbate the condition. However, this opinion is devoid of any substantive rationale. Thus, the Board assigns this opinion low probative value. * In December 2013, the Medical Evaluation Board found the Veteran unfit for service due to his eye condition. * In an October 2018 letter, Dr. J.E.T., an ophthalmologist at the Wilmer Eye Institute, stated that she specializes in uveitis and other inflammatory eye disorders. She stated that the Veteran has been under her care since 2015 for his pars planitis. She stated that pars planitis is not a natural progression of ocular hypertension. However, Dr. J.E.T. opined that that evidence of record suggests that the Veteran’s history of corticosteroid treatments for his pars planitis exacerbated his ocular hypertension. Dr. J.E.T. opined that the Veteran’s pars planitis did not exist prior to his service and is not a natural progression of a preexisting condition. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 4. Following the review and any additional development deemed necessary, re-adjudicate the claim. Should the claim not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claim to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2014). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Timothy T. Emmart 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.