Citation Nr: 21000056 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 17-16 562 DATE: January 4, 2021 ORDER An initial 30 percent rating for right knee recurrent subluxation and patellar instability is granted, subject to the legal authority governing the payment of compensation. An initial 30 percent rating for left knee recurrent subluxation and patellar instability is granted, subject to the legal authority governing the payment of compensation. An n initial rating greater than 10 percent for right knee patellofemoral pain syndrome (PFPS) with decreased flexion is denied. An initial rating greater than 10 percent for right knee PFPS with decreased flexion is denied. An initial 10 percent rating for right peripheral corneal scars/opacities with bilateral conjunctivitis and bilateral dry eye syndrome, prior to February 13, 2020, is granted, subject to the legal authority governing the payment of compensation. .A rating greater than 10 percent for right corneal scars/opacities with bilateral conjunctivitis and bilateral dry eye syndrome is denied. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran’s favor, his left knee recurrent subluxation and patellar instability more nearly approximates severe disability. 2. Resolving all reasonable doubt in the Veteran’s favor, his right knee recurrent subluxation and patellar instability more nearly approximates severe disability. 3. The preponderance of the evidence is against a finding that the Veteran’s right knee PFPS has resulted in flexion limited to 30 degrees. 4. The preponderance of the evidence is against finding that the Veteran’s right knee PFPS has resulted in flexion limited to 30 degrees. 5. Prior to February 13, 2020, the Veteran had active bilateral conjunctivitis. 6. Throughout the period under consideration in this appeal, the Veteran’s service-connected right eye cornea scars/opacities and bilateral conjunctivitis and dry eye syndrome has resulted in itching, irritation, dryness, fluctuations in vision, and discharge. However, his nonservice-connected cataracts have resulted in blur and glare, his nonservice-connected left central serous chorioretinopathy has resulted in blur, he has not had a visual field defect or incapacitating episodes associated with his service-connected right eye disabilities, and his best corrected distance visual acuity has more nearly approximated 20/40 bilaterally or better. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating for right knee recurrent subluxation and patellar instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5257. 2. The criteria for an initial 30 percent rating for left knee recurrent subluxation and patellar instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 3. The criteria for an initial rating greater than 10 percent for right knee PFPS with decreased flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5260-5003. 4. The criteria for entitlement to an initial rating greater than 10 percent for left knee PFPS with decreased flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5260-5003. 5. The criteria for an initial 10 percent rating for right peripheral corneal scars/opacities with bilateral conjunctivitis and bilateral dry eye syndrome, prior to February 13, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.79, DC 6018. 6. The criteria for a rating greater than 10 percent for right corneal scars/opacities with bilateral conjunctivitis and bilateral dry eye syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.79, DC 6018. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from August 1986 to August 1996. His awards include the Southwest Asia Service Medal with Bronze Star, and the Meritorious Unit Commendation. This appeal to the Board of Veterans’ Appeals (Board) arose from a September 2014 rating decision in which a Department of Veterans Affairs (VA) Regional Office (RO), inter alia, granted service connection for right and left knee subluxation and assigned an initial 20 percent rating, each; granted service connection for right and left knee (PFPS) with limited flexion and assigned an initial 10 percent rating, each; and granted service connection for right corneal scars/opacities, and assigned an initial zero percent (noncompensable) rating. Each award was made effective December 6, 2013. The Veteran timely disagreed with, and perfected an appeal as to, each assigned rating. In August 2019, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with claims file. In December 2019, the Board remanded the claims on appeal for current examinations and to request that the Veteran provide releases and information so that VA could obtain private treatment records. The examinations have been completed, and the Veteran did not respond to requests for additional evidence. In a July 2020 supplemental statement of the case (SSOC), the agency of original jurisdiction (AOJ) recharacterized the service-connected right eye disability as right corneal scars/opacities with bilateral conjunctivitis and dry eye syndrome, and awarded a higher, 10 percent rating, effective February 13, 2020. The Board is now satisfied that all notification and development actions needed to fairly adjudicate each claim on appeal has been accomplished, and will proceed to adjudicate the claims, at this juncture. Higher Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). While the Veteran’s entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the disability rating is at issue, generally, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in evaluating a claim for a higher initial rating or increased rating, staged rating is appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007) (for increased rating claims); Fenderson v. West, 12 Vet. App. 119, 126 (1999) (for initial rating claims). Evaluation of Knee Disabilities The Veteran contends that he is entitled to higher ratings for his right and left knee disabilities because he suffers from subluxation, instability, swelling, pain, limitation in exercise, limitation in climbing stairs or walking up ramps, and limitations with sitting or crossing his legs. The Veteran has additionally argued that he cannot fully straighten his knees (has limitation of extension). In August 2019, the Veteran testified that his knee disabilities continued to worsen, and that he had a hard time climbing stairs, and he could no longer run. “Any little impact…will cause dislocation.” When his knee dislocated, it would swell. He stated that some of the dislocations were “quick” and he “pops them in [himself]” which was “quite painful and it remain[ed] swollen for a long time.” It limited his ability to move, climb, and “get around.” He felt that it had changed the way he walked. He stated that he could not “straighten [his] legs all the way out.” He testified that he had been told to consider knee replacements. He felt that his knees had considerably limited him because he could not do the exercises he used to do, and he used to be an avid runner. In July 2014, the Veteran participated in a VA knee examination. He was diagnosed with bilateral patellar subluxation and PFPS. He reported a history of several bilateral patellar dislocations in the Navy. He had constant 4 out of 10 knee pain and episodic swelling with activity. He also had increased pain with climbing stairs. On range of motion testing, he had full knee range of motion (zero to 140 degrees). He had objective painful motion with flexion at 100 degrees of both knees. He was able to perform repeat range of motion testing without loss of range of motion. He had tenderness to palpation of both knees. He had full muscle strength throughout. His joint stability tests were all negative/normal. The examiner noted that the Veteran had a history of recurrent patellar subluxation, both of a moderate severity. At that time, imaging did not show arthritis. Regarding whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during a flare-up or with repeated use over time, the examiner remarked “there is no further impairment” and when asked to describe any functional loss in terms of loss of range of motion, the examiner wrote “no additional limitation.” The examiner provided a positive nexus opinion, noting that the Veteran was seen for bilateral knee pain injury in May 1991 and November 1993. He was seen for right knee patellar dislocation in February 1990. He continued to have chronic knee pain in service, with patellar subluxations. This examination confirmed bilateral PFPS and patellar subluxation, as noted in his service treatment records. The Board notes that the 2014 examination included that the Veteran had three “scope” scars measuring 5 mm x 2mm from knee surgeries. A 2014 scar examination noted that the scars were not painful or unstable. A September 2014 rating decision granted entitlement to service connection for knee surgery scars, with a noncompensable evaluation. The Veteran did not appeal the initial scars rating. On his September 2015 Notice of Disagreement (NOD), the Veteran argued for an increased rating for his knees because they “continued to degrade,” with constant pain at rest, constant pain with walking and climbing stairs, lack of stability, inability to support his weight, lack of mobility (such as no running), loss of flexibility (the knees lock in place when climbing stairs), and the right knee constant felt as though it was going to dislocate. A September 25, 2015 VA primary care treatment record which indicates that the Veteran was establishing care with VA, notes his concern about both of his knees, and history of multiple surgeries for both. He was still active with swimming and surfing, but traveling “took a toll on his knees.” He had knee injections in the past. X-rays from 2014 were noted to show right knee patellar enthesopathy and left knee prior tibial collateral ligament injury and early patellofemoral degenerative arthrosis. On December 23, 2015, the Veteran was seen by VA physical therapy for consultation regarding his knee complaints. He reported an extensive surgical history, with 8 surgeries on the left knee and 9 surgeries on the right knee. The Veteran was working full time. His gait was non-antalgic, with good foot/toe clearance, and equal stride length. His knee range of motion was 0 to 120 bilaterally. He had negative Lachman and valgus/varus tests. He had tenderness to palpation of the peripatellar and along MJL/LJL. He had no pain (negative) on the unilateral mini-squat test. The Veteran’s’ goal was to alleviate his pain, but he did not believe anything could be done for him other than what he was “already doing with flexibility and generalized strengthening including stationary bike.” The physical therapist noted that “testing today shows [bilateral] knees absent of swelling and patient has no [complaints of] instability/giving way, falls, locking of knees. Patient has no desire to brace the knees and states that he is performing home program to maintain flexibility and strength in knees.” He was discharged from physical therapy. On September 27, 2016, the Veteran participated in a fee-basis (contractor) VA knee examination wherein he was diagnosed recurrent subluxation, PFPS, and knee joint osteoarthritis (left only). The Veteran reported the onset of symptoms with a knee dislocation in 1990, and that his condition had worsened with time. He described right knee flare-ups as “constant throbbing pain,” and left knee flare-ups as “constant stabbing pain.” He also reported functional impairment of “cannot put full weight on left leg.” Range of motion testing for his right knee was “all normal.” Pain was not noted on examination. He had mild objective tenderness of the medial joint line. There was no evidence of crepitus. The Veteran’s left knee range of motion was from zero to 110. The abnormal range of motion resulted in difficulty squatting. He had moderate objective tenderness of the medial joint line. There was no evidence of pain with weightbearing or crepitus. After repetitive use testing, his ranges of motion for his knees remained the same. The examiner was unable to estimate any additional loss of range of motion after repeated use over time or during a flare-up because the Veteran was “unable to objectively express loss of [range of motion], so it would only be with mere speculation that [the examiner] could come up with an accurate description of [range of motion.]” The Veteran had additional right knee symptoms of swelling, disturbance of locomotion, and interference with standing. His left knee had symptoms of less movement than normal, swelling, deformity, instability of station, and interference with standing. He had normal strength throughout. He did not have ankylosis. He was noted to have a history of moderate right recurrent subluxation and severe left recurrent subluxation. He did not have a history of lateral instability. Joint stability testing was normal throughout. The examiner selected that the Veteran did not have a history of a meniscus condition. X-rays were noted to show arthritis of the left knee only. Regarding the Veteran’s functional impairment, he “described difficulty with prolonged walking, sitting, and squatting.” On September 27, 2016, the VA examiner provided an addendum statement that clarified the severity of the Veteran’s subluxation as “moderate patellar subluxation, on and off, with no influence on stability.” A February 23, 2018 VA primary care record that indicates that the Veteran was re-establishing care with VA notes his complaint of left knee instability, with prior physical therapy that had “not been helpful.” He had a patellar stabilizing knee brace for the left knee ordered two weeks prior. The Veteran reported a sensation of falling and had fallen once. An MRI of the left knee was ordered. An April 8, 2019 VA primary care annual evaluation report documents the Veteran’s report of working “2 full-time jobs.” The record cited a March 2018 left knee MRI where no ligamentous insufficiency was identified. The findings were suggestive of a remote injury to the medial collateral ligament. “MRI of L knee in March 2018 showed no ligamentous injury and distant injury to the medial collateral ligament. Currently not having any issues with it.” Following the December 2019 Board remand, the Veteran was afforded another VA knee examination on February 11, 2020. In the report, the examiner cited an April 2019 VA treatment record noting a history of left knee instability with a sensation he was going to fall and has fallen once, a July 2014 record noting a fall, and a 2016 physical therapy record which noted the Veteran’s denial of instability/giving way/falls/locking. The examiner diagnosed bilateral PFPS, left degenerative arthritis, bilateral patellar instability, bilateral patellar subluxation, and bilateral patellar tendonitis (enthesopathy). The noted history includes that the Veteran developed knee pain on rocking ships with arthroscopy on both knees while in service, and had “fluid drained” during service. His current symptoms were that his patella popped out easily on both sides, right popped out 2-3 times per year. His right knee locked 2-3 times in 2019 and left had locked once. He noted falling down the stairs on one occasion when his knees locked. He stated that he avoided activities that may result in popping out his patellas, and was “very protective of his knees, especially the right.” He reported constant pain, worse with sitting for too long, and pain with crossing his legs. He treated his knees with ice, Ibuprofen, and Tylenol. He wore a brace, and he stated a private physician recommended replacement. His flare-ups of knee symptoms were described as “when the patella pops out, when climbing stairs or steep ramps.” He described functional loss as unable to run or exercise (he had previously been a runner). On examination, the Veteran’s right knee range of motion was from zero to 70 degrees. His range of motion contributed to functional loss as he “cannot bend deep.” He had objective mild pain in his patella during flexion due to his PFPS. There was evidence of pain with weightbearing. His left knee range of motion was from zero to 95 degrees. His range of motion contributed to functional loss with “difficult to bend deeply at the knees.” He had objective mild patella pain due to PFPS, and pain with weightbearing. He did not have crepitus of either knee. The Veteran was able to perform repeat range of motion testing, and had additional right range of motion loss of flexion to 65 degrees. His extension remained full (to 0). His left knee range of motion remained the same after repeat testing. The examiner noted that the Veteran was not examined immediately after repetitive use over time, but the examination was medically consistent with the Veteran’s statements describing functional loss. The examiner noted that pain significantly limited his functional ability. The examiner estimated that he would have additional functional loss with repeated use over time with range of motion decreasing to from zero to 60 degrees. The examiner had similar findings related to the Veteran’s left knee, and estimated his additional loss of range of motion would be from zero to 85 degrees. The examiner noted that the Veteran was not examined during a flare-up, but the examination was medically consistent with the Veteran’s description of functional loss during a flare up. Again, the examiner estimated that the Veteran’s range of motion during a flare-up would be zero to 60 degrees right and from zero to 85 degrees left. The Veteran had full (5/5) muscle strength on testing. He did not have ankylosis of either knee. The joint stability section noted that the Veteran had moderate bilateral recurrent subluxation and slight bilateral lateral instability. There was no history of recurrent effusion. Joint stability testing (anterior, posterior, medial, and lateral) were all normal bilaterally. However, the examiner noted “patella instability noted: right patella very mobile and can be moved 5 mm, left patella can be moved manually 4 mm,” but he was not able to “easily completely sublux” either. The examiner also selected that the Veteran had recurrent patellar dislocation of a moderate severity. The Veteran was noted to wear a brace for instability. The examiner noted that degenerative arthritis was shown in the left knee only. The functional impact statement was “precludes strenuous activity, stair climbing, excessive walking and prolonged standing.” Regarding the Correia criteria, there was no objective evidence of pain on non-weight bearing. His passive range of motion was the same as his active range of motion for his right knee. For his left knee, his passive range of motion was from zero to 100 degrees. His pain was present the same for both knees as for his active range of motion. The examiner noted that all the diagnosed knee conditions were related to the Veteran’s service and/or a natural progression of his service-connected knee conditions. Over time, the Veteran’s PFPS and recurrent subluxation caused tendonitis by causing repeated inflammation of the patella tendon causing tendonitis. PFPS “can cause arthritis over time due to altered mechanics and excess wear and tear on the knee joint.” The Board notes that the September 2020 Brief submitted by the Veteran’s representative argued that the 2020 VA examination “failed to address instability and subluxation and in regard to evaluations and to provide separate evaluations accordingly.” The representative requested that the Board remand the Veteran’s knee claims for additional examination to address instability and subluxation. The Board finds that the 2020 examination did an adequate job addressing instability and subluxation. The examiner included the Veteran’s lay statements/complaints regarding feelings of giving way, falling, and instability. The examiner cited prior records addressing the Veteran’s complaints and denials related to instability. The examiner completed the VA examination report sheet with instability testing, but also provided additional information on the Veteran’s patella movement and stability which are not a part of the form examinations. Although not argued, the Board also finds that the 2020 examination adequately addresses the Veteran’s range of motion, including passive, active, pain with weightbearing, pain on non-weightbearing, loss of motion with repeated use over time, and loss of motion during a flare-up. As such, the 2020 examination is adequate upon which to provide rating analysis in this decision. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or § 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court)t held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran’s right and left knee subluxation and patellar instability are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under Diagnostic Code 5257, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board observes that the words “slight,” “moderate,” “severe,” and “pronounced” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “slight” and “moderate” by VA examiners or other physicians, although an element of 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. Currently, the Veteran is in receipt of separate 20 percent ratings for each knee for recurrent subluxation of a “moderate” severity. The Board finds that the evidence supports that his recurrent subluxation and patellar instability more closely approximate a “severe” disability, and warrant separate 30 percent ratings for each knee. As noted above, the Veteran reports subluxation up to 3 times per year. VA examiners have noted that his subluxation is of a “moderate” severity. He additionally has complained of feelings of instability, and a need to be “very careful” with his knees and how he moves so that he does not fall or have subluxation. Although his lateral instability tests have all been negative/normal, the most recent examiner noted that he has patellar instability, and noted that he had “slight” lateral instability. The Board finds that the combination of his “moderate” recurrent subluxation, “slight” lateral instability, and patellar instability equates to severe disability. A 30 percent rating, for severe recurrent subluxation or lateral instability, is the highest schedular rating under DC 5257. Entitlement to initial 30 percent ratings for right and left knee recurrent subluxation and patellar instability are warranted for the entire period on appeal. The Veteran’s 10 percent ratings for right and left knee PFPS with decreased flexion were assigned under DC 5260. The assigned diagnostic code suggests that his PFPS is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the PFPS has manifested as osteoarthritis (left) and was initially rated based on painful noncompensable limitation of motion. Therefore, the Diagnostic Code assigned should have been DC 5003, to show that the PFPS with osteoarthritis was being rated based on noncompensable limitation of motion that is painful. The Board notes that the Veteran’s right knee has not been shown to have arthritis on imaging. However, the September 2014 rating decision on appeal provided separate 10 percent ratings for each knee based on 38 C.F.R. § 4.59 for painful motion. For this reason, the Board is changing the DC for the PFPS to 5003-5260 to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. Under DC 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. As noted above, in July 2014, the Veteran’s bilateral knee range of motion was listed as full (from zero to 140 degrees) with objective pain at 100 degrees. By December 2015, the Veteran’s bilateral knee range of motion was from zero to 120 degrees. The 2016 examination listed his right knee range of motion as “normal” (zero to 140 degrees), and his left knee range of motion as zero to 110 degrees. During his 2019 Board hearing, the Veteran reported that his knee range of motion had worsened since his 2016 examination. This was confirmed by the 2020 examination, which showed right knee range of motion from zero to 70 degrees, and left knee range of motion from zero to 95 degrees. The Board notes that the range of motion testing prior to the 2020 examination did not include passive range of motion, estimated range of motion following repeated use, and/or estimated range of motion during a flare-up. As such, the range of motion described during the 2020 examination provides the basis for the rating analysis. However, the prior examinations and treatment record give background information on the Veteran’s active range of motion not during a flare-up or after repeated use over time. The 2020 examination included that during a flare-up or after repeated use over time, the Veteran’s estimated additional loss of range of motion based on his description of functional impairment would be zero to 60 degrees for his right knee and zero to 85 degrees for his left knee. As noted above, flexion limited to 60 degrees warrants a noncompensable rating under DC 5260. Although the Veteran’s right knee was estimated to be limited to 60 degrees, even a slightly greater estimated limitation would not meet the criteria for a compensable rating under DC 5260, which requires flexion limited to 45 degrees for a 10 percent rating. The Veteran has been provided separate 10 percent ratings for his bilateral knee PFPS with decreased flexion based on objective pain with loss of flexion that does not meet the criteria for a compensable rating. These ratings are based on 38 C.F.R. § 4.59 due to painful motion. As such, the Board finds that an initial rating in excess of 10 percent for PFPS with decreased flexion is not warranted. The Board has also considered the applicability of other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). During the Board hearing, the Veteran testified that he could not “fully straighten” his knees. It was unclear if he was referring to an occasional inability to fully straighten his knees, or if he felt that they were never fully straightened. However, VA examinations and physical therapy records showed that the Veteran had full extension (to zero degrees) on all objective tests. Although the Board considers the Veteran’s statement that he cannot always “fully straighten” his knees to be credible, there is no evidence to suggest that his extension has been limited to 10 degrees or greater such that a separate compensable rating may be warranted. Most recently, during his 2020 examination, repeat range of motion testing resulted in further decreased flexion but did not impact his ability to fully extend his knees. The examiner estimated that he would have additional loss of flexion with repeated use over time and during a flare-up, but did not find that there would be loss of extension. Although the Veteran has indicated there is some loss of extension, this has not been objectively seen or measured, and a compensable rating for loss of extension requires that the loss be to 10 degrees or greater. The preponderance of the available evidence does not support that the Veteran’s knee disabilities result in a compensable disability related to his extension of the knees. The Board notes that the Veteran does not have ankylosis of either knee, as shown both by VA examiners finding that he did not have ankylosis, but also by the range of motion reported by the medical and lay findings of record. As such, a separate or greater rating under DC 5256 is not warranted. DC 5258 and 5259 provide ratings based on dislocated semilunar cartilage and symptomatic removal of semilunar cartilage. The Board notes that the Veteran has complained of locking, pain and effusion to the knee, which is described in DC 5258 for dislocated semilunar cartilage. However, VA examiners have noted that the Veteran does not have a history of semi-lunar cartilage conditions, and his collateral ligament injury is noted to cause the pain, effusion, and instability for which he is currently receiving a 30 percent rating under DC 5257. The rule against pyramiding is addressed in 38 C.F.R. § 4.14, which notes that evaluation of the “same disability” or the “same manifestation” under various diagnoses is to be avoided. DC 5262 provides ratings for malunion and nonunion of the tibia and fibula. Although the Veteran has patella instability and began using a brace during the period on appeal, the medical records do not show that he has nonunion of the tibia and fibula. The ratings for malunion of the tibia and fibula are based on slight, moderate, or marked knee disability and do not provide a rating greater than 30 percent. As such, separate ratings under DC 5262 would constitute pyramiding, and the criteria for a 40 percent rating (requiring nonunion) are not met. The Board finds that the preponderance of the evidence is against additional separate ratings for the Veteran’s knee disabilities. His lay reports of symptoms of giving way, subluxation, effusion, pain, and locking resulting in difficulty walking up stairs and ramps, difficulty squatting, inability to cross his legs, and limitation in recreational and exercise activities are contemplated by the separate 30 percent and 10 percent ratings he had been provided for each knee. Although his complaint of limited extension is not currently compensated, it has not been shown to meet the criteria for a separate compensable rating as yet. The Veteran has reported he has been advised he may need a knee replacement in the future. As of the most recently available records, it does not appear that he has undergone knee replacement surgery during the period on appeal. In conclusion, the Board has resolved all reasonable doubt in the Veteran’s favor in finding that a higher, 30 percent rating, each, for bilateral subluxation and patellar instability, but finds that the preponderance of the evidence is against a rating greater the in excess of 10 percent for PFPS with decreased flexion. In denying any higher or separate rating, the Board finds the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. at 49, 53-57 (1990). Evaluation of right peripheral corneal scars/opacities with bilateral conjunctivitis and bilateral dry eye syndrome The Veteran contends that his right eye corneal scars/opacities and bilateral chronic conjunctivitis and dry eye syndrome warrant a higher rating. He also argues that symptoms which have been associated with cataracts should be considered in his rating for his service-connected eye conditions. During his August 2019 Board hearing, the Veteran testified that he had “continual visits to the VA doctor about [his] vision” and that it had “deteriorated rather quickly over the last couple of years.” He stated he was almost “legally blind in one eye” and felt he would not be able to do his job any longer because he was dependent on his vision. He was getting new prescription glasses every 6 to 9 months. He also stated that his eyes “constantly water” due to the chemical burns he received in service. He stated that VA had “drained the liquid out of [his] eyes” and given him different eye drop medications. The Veteran argued that his vision loss was a “continued problem” that “originally happened” in service and that he had no “hereditary issue with vision in [his] family.” He felt that his in-service injury combined with his age had made his vision worse, as “chemical issues…[never] go away.” He testified that the “constant chemicals that are coming out of [his] eyes… [made his] vision wave, [made] it hard to see” and impacted his job. He also noted he had irritation with his eyes such that he had to “constantly blink” to let the “moisture build up.” He stated he would be “legally blind within a couple of years.” When asked if he had any eye conditions other than his corneal scars, the Veteran stated that the last time he saw an eye doctor he was told he had “really bad cataracts in both eyes” and he was “not sure how that [was] possible.” He stated he was on a list for lens replacement, which would correct the lenses in “the back of [his] eyes” but would not correct his vision. The Veteran filed a claim of entitlement to service connection for his eye conditions in June 2013. In June 2014, the Veteran participated in a VA eye examination in conjunction with his claim for benefits. He was diagnosed with corneal scars related to corneal damage, dry eye syndrome, and corneal foreign bodies related to corneal damage. He also had “pinguecula not related to corneal damage.” His bilateral corrected distance vision was 20/40 bilaterally. On slit lamp evaluation, he had nasal and temporal pinguecula of the bilateral conjunctiva, and 3 corneal opacities inferotemporal of the right cornea. He had otherwise normal slit lamp, external, and fundus evaluations. He did not have a visual field defect. Under conjunctival conditions, the Veteran was noted to have bilateral pinguecula. Regarding its impact on his visual acuity, the examiner selected that the Veteran did not have visual impairment or decreased visual acuity. His right corneal opacities were also noted to not impact his visual acuity because he did not have decreased visual acuity or visual impairment. The examiner selected that the Veteran did not have scarring (skin), disfigurement, or incapacitating episodes. In providing a positive nexus opinion, the examiner noted that the Veteran’s right eye corneal opacities were consistent with those routinely found following metallic foreign body injury. Under DC 6066, vision of 20/40 or better in both eyes warrants a noncompensable rating. In his September 2015 NOD, the Veteran argued that his vision continued to “degrade.” He stated that he chemical explosion in service had given him “both dry eyes and overly moist eyes.” He noted his prescription glasses had “become stronger” and that his vision without glasses was such that he could not see clearly outside of 5 to 7 feet. Also, he could not read without his glasses. He stated his eye doctor had told him his vision was “deteriorating at a very rapid rate.” An October 9, 2015 VA optometry record included the Veteran’s complaint of blurry left vision for 3 months. He stated he flew “out east” and his vision had not been the same since. He also felt his eyes were very “itchy/gritty.” He had previously used Pataday with good relief, but does not use it anymore. He denied pain, flashes, and floaters. His visual fields were full to finger counting. His left macula showed “moderate elevation (likely [central serous chorioretinopathy]), small choroidal nevus approximately ¼ DD superior to fovea.” His right macula was flat and intact. He was assessed with likely acute central serous retinopathy of the left eye for three months. He was noted to have a high stress job and to drink large amounts of tea. He denied recreational or prescribed steroid use. He also had a left choroidal nevus. He had corneal deposits in the right eye likely due to history of foreign body/chemical burn, “asymptomatic with good acuities (best corrected visual acuity 20/20 right eye). He had hyperopic astigmatic presbyopia of both eyes, and bilateral allergic conjunctivitis with prior good results with Pataday.” On November 24, 2015, the Veteran complained of “scratchy/itchy” left eye to VA ophthalmology. He had previously used Pataday with good results, but he had stopped using it due to its cost. He had not noticed a change in vision. His corrected vision was 20/20 right and 20/40 left. He was assessed with likely acute central serious retinopathy of the left eye for 3 months. He again denied steroid use. By January 26, 2016, the Veteran was seen by VA ophthalmology for follow-up and he had “no complaints and stable visual acuity.” His corrected visual acuity was 20/20 right and 20/25-1 left. The Veteran’s left lower lids had meibomian gland capping, his right cornea had small shiny white subepithelial deposits nasally, and clear cornea of the left eye. He had 1+ nuclear sclerotic cataracts of both eyes, with trace PSC (posterior subcapsular cataracts) right more than left. His left macula had no pigmentary changes. The assessment was of likely acute central serous retinopathy left eye for three month and left choroidal nevus. In September 2016, the Veteran participated in a fee-basis (contractor) VA examination. He was diagnosed with corneal scars right eye (from 1991) and left eye amblyopia (from 1986). The history section noted that the Veteran suffered right corneal scars in 1991 following an explosion near his face. He noted that metal was removed from his right eye. He also noted a prior history of a “lazy left eye” diagnosed in 1986 or 1987. His corrected distance vision was 20/40 right and 20/70 left. On slit lamp evaluation, the Veteran had 3 stromal scars inferiorly of the right cornea. He was otherwise noted to have normal slit lamp and fundus evaluations. The Veteran did not have a visual field defect. The examiner did not select that the Veteran had a disorder of the lacrimal apparatus, and did not select that the Veteran had a conjunctival condition. Regarding his corneal condition, the examiner noted the Veteran had not had a corneal transplant. The examiner noted that the Veteran did not have a decrease in visual acuity or visual impairment. The examiner selected that the Veteran had scaring or disfigurement attributable to his eye condition, noting “small anterior inferior corneal stromal scars right eye, none of the listed conditions apply” (referring the listed characteristics of disfigurement). The examiner found that he had not had any incapacitating episodes in the prior 12 months. Regarding the functional impact of his eye disabilities, the examiner noted that his ability to work was “slightly decreased vision in the left eye which had amblyopia—could affect depth perception.” The Board notes that this examination did not include findings for cataracts, conjunctivitis, or dry eyes. Although conjunctivitis can be active or inactive, the Veteran’s cataracts would have been present during the examination. As such, the Board will assign less weight to the findings in the 2016 examination. Under DC 6066, vision of 20/70 in one eye and 20/40 in the other warrants a 10 percent rating. A February 6, 2018 VA ophthalmology record included the Veteran’s report of decreased vision. He denied eye pain. His corrected vision was 20/20-2 right and 20/30 left. Slit lamp evaluation showed “white” conjunctivae/sclera, and lids/lashes within normal limits. He had 3 small, inferior subepithelial opacities in the right cornea, and a clear left cornea. He had mild central PSC right lens and clear left lens. On dilated posterior pole evaluation, he had clear vitreous, sharp nerves, and his macula, vessels, and peripheries were within normal limits. He was assessed with a history of central serous chorioretinopathy, with denial of any steroid use, and no fluid on evaluation. He also had right eye cataracts, and bilateral refractive error. He was to be seen again in a year. On March 20, 2018, the Veteran was seen by VA optometry with a complaint of blurry vision at distance and near. His corrected visual acuity was 20/30 right and 20/40 left. He was assessed with hyperopia, astigmatism, and presbyopia bilaterally with best corrected visual acuity was 20/20-2 right and 20/30 left. The optometrist noted this was stable. Under DC 6066, vision better than 20/40 in both eyes warrants a noncompensable rating. On February 6, 2019, the Veteran was seen by the VA eye clinic for complaints of worsening distance and near vision. Also, his eyes were “very oily at times, especially after working on computer.” He denied eye pain, but noted a burning to the dry sensation when using the computer. His corrected vision was 20/30-1 right and 20/50-2 left. Under DC 6066, vision of 20/50 in one eye and 20/40 in the other warrants a 10 percent rating. The Veteran was seen six weeks later, on March 27, 2019, seeking an updated prescription. His corrected visual acuity was20/20 right, and 20/30 to 20/25 left (hyperopic astigmatism bilaterally, presbyopia). This was noted as “mildly reduced acuity” left eye with a history of central serous retinopathy. He was assessed with dry eye syndrome “WC/lid hygiene.” He was not yet interested in artificial tears. History of CSCR and denied steroid use in any form. He also had cataracts, which they were monitoring. On February 7, 2020, the Veteran was seen by VA ophthalmology with a history of acute central serous retinopathy of the left eye for one-year follow-up for a dilated fundus examination. He stated that his “prescription isn’t holding up.” He had more problems reading, and glare was “murderous” with glasses. His corrected visual acuity was 20/40-2 right and 20/40-1 left. He also has his brightness acuity tested. In low and medium light, he had 20/60-1 right and 20/40-1 left, and in high light he had 20/70 right and 20/50 left. His retinal acuity meter showed 20/30-2 right and 20/30 left. On slit lamp evaluation, he had meibomian gland disorder of the lower lids, and 3 small, inferior, subepithelial white opacities without EPI [epithelial] defect, right eye. He had a clear left cornea. He was assessed with bilateral cataract, with a notation that the Veteran was “bothered by glare, interested in multifocal lens.” He also had a history of central serous chorioretinopathy (CSR) previously. However, the ophthalmologist noted that the Veteran never had SRF (subretinal fluid) or pigmentary changes, OCT (optical coherence tomography) mac normal without any changes in the outer retina, “unlikely patient ever had CSR.”. On March 27, 2020, the Veteran participated in another VA eye examination. The examiner recited some of the Veteran’s medical history from the electronic file, including diagnoses from the June 2014 examination, October 2016 examination, and treatment records from October 2015, and February and March 2019. His diagnoses were listed as: cataract right eye, peripheral corneal opacities right eye, bilateral allergic conjunctivitis, bilateral dry eye syndrome, bilateral pinguecula, left eye maculopathy from resolved central serous chorioretinopathy, and right corneal scars related to corneal damage status post foreign body and chemical exposure. His right corneal opacities and damage were from a 1987 injury from the explosion of an A/C unit and exposure to metal and freon. His dry eyes and conjunctivitis began in 1987 as well. His right cataracts were diagnosed in 2019, and his central serous chorioretinopathy of the left eye was diagnosed in 2015. Regarding symptoms, his corneal opacities were asymptomatic. His dry eyes and conjunctivitis resulted in itching, irritation, dryness, fluctuations in vision, and discharge. His right cataracts resulted in blur and glare. And his left central serous chorioretinopathy resulted in blur. His corrected distance vision was 20/40 bilaterally. He did not have diplopia. He did not have visual field defect. On slit lamp evaluation, the Veteran had turbid meibum and capped glands of the bilateral lids. He had nasal/temporal pinguecula, 2+ tarsal papillae, and 2+ bulbar injection/chemosis of the conjunctiva and sclera. He had 3 inferior opacities/foreign bodies in his right cornea. He had bilateral delayed tear break up time. He had 1+ nuclear sclerotic cataracts and right on-axis PSC. On internal eye examination, the Veteran had inferior RPE (retinal pigment epithelium) disruption, and superior juxta foveal nevus of the left macula. The Veteran’s bilateral pinguecula were “visually insignificant.” The examiner noted that the Veteran did not have a disorder of the lacrimal apparatus. He had dry eye syndrome since 1987. He did not use any treatment for his dry eye syndrome. His dry eye syndrome was not visually significant. The Veteran’s right peripheral corneal opacities/foreign bodies did not result in visual impairment or decrease in visual acuity, “visually insignificant.” His bilateral pre-operative cataracts resulted in his decreased visual acuity/visual impairment. His left maculopathy from resolved central serous chorioretinopathy also resulted in his deceased visual acuity/visual impairment. The examiner found that the Veteran did not have scarring or disfigurement, and he had not had any incapacitating episodes due to his service-connected eye disabilities in the prior 12 months. The Veteran reported functional impact of “reduction in visual acuity interferes with reading and driving.” In the opinion section, the examiner noted that the Veteran’s peripheral corneal opacities right eye, dry eye syndrome bilateral, and conjunctivitis bilateral were related to his in-service injury. The examiner noted that dry eye syndrome and chronic conjunctivitis can develop due to damage to the ocular surface/cells that produce tear film caused by chemicals (freon, etc.) that when into his eyes. “Peer-reviewed medical literature supports the association between chemical injury and dry eye/chronic conjunctivitis.” In an addendum statement, the examiner noted that the Veteran’s conjunctivitis was active. The examiner opined that the Veteran’s cataracts, pingueculae, and maculopathy were likely unrelated to service since they had their onset well past his 1996 military separation and his service treatment records were silent for these conditions or any causative events. “Per medical evidence review, they were diagnosed well past military separation. The in-service injury affected the ocular surface, not the internal contents (lens/retina). [Service treatment record] is silent for cataract/CSR or causative events. Pingueculae were not diagnosed until 2014 and STR is silent for pingueculae/causative events. Pingueculae is not visually significant.” The Veteran’s cataract was noted to be cause of his gradually blurring vision. A June 26, 2020 VA treatment record included the Veteran’s complaint of decreased vision in his right eye for several years, described as hazy vision, difficulty reading, and difficulty with glare at night. Evaluation of his eyes showed a haze right cornea. His vision was 20/30 right and 20/30-2 left. He had bilateral lower lid MGD, and three small, inferior, subepithelial white opacities without EPI defect in the right cornea. He had a clear left cornea. He was assessed with visually significant cataracts of both eyes with blurred vision event with glasses, difficulty reading and driving, and CSR stable. On July 7, 2020 the Veteran underwent cataract surgery with intraocular lens placement in his right eye. On July 8, 2020, he reported that he was “very happy with his vision.” Two weeks later he underwent the same surgery on his left eye. The September 2020 Brief submitted by the Veteran’s representative argued that the 2020 VA examination was inadequate because it did not address incapacitating episodes and requested remand to address incapacitating episodes. The Board notes that the 2020 examination did address incapacitating episodes, and found that the Veteran had not had any incapacitating episodes associated with his service-connected eye conditions in the prior 12 months. The Brief did not cite any incapacitating episodes or treatment records in support of a finding of incapacitating episodes. The Veteran did not respond to a request for copies of or releases for private treatment records. As such, the Board finds the 2020 examination to be adequate and that remand for additional examination is not required. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. Id. § 4.75(b). Examinations of visual field or muscle function will be conducted only when medically indicated. Id. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Currently, the Veteran is in receipt of staged ratings, with a 10 percent rating for his right corneal scars/opacities with bilateral conjunctivitis and dry eye syndrome from February 2020 based on active conjunctivitis. Both the former and revised criteria under DC 6018 for chronic conjunctivitis (nontrachomatous) distinguished active and inactive disease processes. Under the former criteria, an active disease process (with objective findings, such as red, thick conjunctivitae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (DC 7800). With regard to visual impairment, the May 2018 amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. The General Rating Formal for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. For brevity, the Board will not recite the ratings for incapacitating episodes, but will note how an incapacitating episode is defined from May 2018 onward. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The Board notes that prior to the February 2020 VA examination, the Veteran was noted to have allergic conjunctivitis in 2015, and to have complaints of itchy/scratchy eyes prior to 2020. As such, the Board will provide the 10 percent rating under DC 6018 for the entire period on appeal. Next, the Board will consider whether an additional rating in excess of 10 percent is warranted for conjunctivitis. As noted above, the Veteran’s visual acuity has fluctuated during the period on appeal. In September 2016 and February 2019, the Veteran’s visual acuity reached the level of a 10 percent rating under DC 6066. His vision in high light in February 2020 reached the level of a 20 percent under DC 6066. However, all of his other cited visual acuities were 20/40 or better bilaterally (including under regular light in February 2020) which warrants a noncompensable rating under DC 6066. Following the fluctuations in September 2016 and February 2019, the Veteran had updated prescription glasses provided. The Board additionally notes that the Veteran’s visual impairment/decrease in visual acuity has been attributed to his nonservice-connected bilateral cataracts and left CSC. Given that the majority of the Veteran’s best corrected distance visual acuity have been at the noncompensable level during the period on appeal, the notations of vision meeting the 10 percent rating were prior to new prescriptions, the finding related to his vision meeting the 20 percent rating was based on his vision during specific lighting, and the 2020 examiner and treating ophthalmologist noting that the Veteran’s decreased visual acuity was due to his cataracts, the Board finds that an increased rating based on visual acuity is not warranted. The Board notes that the Veteran has argued that his cataracts and left central serous chorioretinopathy “must” be due to his in-service corneal eye injury and exposure to chemicals in both eyes because he did not have a family medical history of any eye conditions. However, the 2020 VA examiner provided a negative nexus opinion relating the Veteran’s cataracts to his in-service injuries noting that the chemical injury and foreign body injury to his right cornea were associated with injury to the ocular surface. Cataracts, however, is associated with “internal contents (lens/retina)” which would not have been impacted by chemical exposure or right cornea injury (additionally, the Veteran had bilateral cataracts). Additionally, as noted by the 2020 examiner, these conditions were diagnosed approximately 10 years and more than the Veteran’s separation from service. As such, the Board does not find that the Veteran’s bilateral cataracts and/or left central serous chorioretinopathy are not service-connected and the symptoms and visual impairment caused by both are not considered in rating the Veteran’s service-connected eye conditions. The Board notes that the Veteran was additionally noted to have pinguecula during his 2014 examination. His pinguecula was not addressed throughout the majority of his VA treatment records, but were again noted during the 2020 examination. The 2020 examiner provided a negative nexus opinion regarding the Veteran’s pinguecula, arguing that pinguecula was not documented during service or for more than 10 years after service and that, according to medical review, there were no events in service which might cause pinguecula. Regarding the Veteran’s representative’s contention that the 2020 examination did not address whether the Veteran warranted an increased rating based on incapacitating episodes, the Board notes that the examiner selected that the Veteran did not have any incapacitating episodes of service-connected eye disability in the prior 12 months. Regarding the former definition of incapacitating episodes (acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider), the Board finds that additional increased ratings based on incapacitating episodes is not warranted. The medical evidence prior to May 2018 did not show that the Veteran had severe right cornea scar/opacities, conjunctivitis, and dry eye syndrome such that he required bedrest and treatment by a healthcare provider. The Veteran was prescribed Pataday for his eyes, which he used with good relief until the price was prohibitive, after which he did not use artificial tears or lubricants. These medications do not meet the level of treatment such as they may be found similar to the treatments provided in Note (2) for incapacitating episodes as defined under the revised criteria (above). Pataday is an antihistamine for allergic conjunctivitis treatment, and is not similar in severity to systemic immunosuppressants, intraocular injections, laser treatment or surgical treatment. The Board notes that the Veteran was seen for complaints related to blurred vision on several occasions for his left central serous chorioretinopathy, but these appointments did not result in “treatment” such as those described in the revised incapacitating episodes definition. He also underwent surgery for his cataracts in 2020. However, the Board has found that his left central serous chorioretinopathy and cataracts are not a part of his service-connected eye conditions. As such, entitlement to a higher rating based on incapacitating episodes is not warranted. Moreover, the Veteran’s service-connected bilateral dry eye syndrome has not been treated with medication, and he has denied use of over-the-counter artificial tears. He has meibomian gland dysfunction with “oily” lids and has been directed in “lid hygiene” for treatment. Examiners have noted that he does not have any disorders of the lacrimal apparatus that result in his dry eye syndrome. For all the foregoing reasons, the Board has resolved all reasonable doubt in the Veteran’s favor in awarding an initial, 10 percent for right eye cornea scars/opacities and bilateral conjunctivitis and dry eye syndrome prior to February 13, 2020, but finds that the preponderance of the evidence is against assignment of any higher rating for the disabilities at any pertinent point. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-57. JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, 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.