Citation Nr: 21003673 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 18-43 685 DATE: January 22, 2021 ORDER Entitlement to service connection for myasthenia gravis, to include as due to exposure to herbicide agents, is denied. Entitlement to service connection for an eye disability, to include as secondary to myasthenia gravis, is denied. FINDINGS OF FACT 1. The Veteran’s myasthenia gravis did not begin during active service and is not otherwise related to an in-service injury or disease. 2. The Veteran’s eye disability did not begin during active service and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for myasthenia gravis are not met. 38 U.S.C. §§ 1110, 5103, 5103A (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2019).  2. The criteria for service connection for an eye disability are not met. 38 U.S.C. §§ 1110, 5103, 5103A (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2019).  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1965 to May 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Board issued a decision granting service connection for bilateral hearing loss and denying service connection for myasthenia gravis and a related eye disability. The Veteran appealed the August 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2019 Order granting a Joint Motion for Partial Remand (JMPR) the Court vacated the Board’s August 2019 decision with respect to the denial of service connection for myasthenia gravis and a related eye disability and remanded the claim to the Board for readjudication. Service Connection 1. Entitlement to service connection for myasthenia gravis, to include as due to exposure to herbicide agents, is denied. 2. Entitlement to service connection for an eye disability, to include as secondary to myasthenia gravis, is denied. The Veteran claims that his currently diagnosed myasthenia gravis is due to his active duty service, to include his presumed exposure to herbicide agents. He also claims that he has an eye disability which is related to his myasthenia gravis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303.  The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).  Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. If a Veteran was exposed to an “herbicide agent,” such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be presumptively service connected even if there is no record of the disease in service. 38 U.S.C. §§ 1110, 1116, 1131; 38 C.F.R. §§ 3.307 (a)(6), (d), 3.309(e).  The Board finds that the Veteran had active duty service in the Republic of Vietnam during the presumptive period, and there is no affirmative evidence of the contrary, so exposure to herbicide agents is presumed.  However, in this case, myasthenia gravis, drooping eyelid, or double vision are not among the list of diseases that are presumed to be related to herbicide agent exposure under 38 C.F.R. § 3.309 (e). As such, presumptive service connection for these disabilities based on herbicide agent exposure is not warranted. Notwithstanding the foregoing presumptive provisions, a claimant is not precluded from establishing service connection for a disease averred to be related to herbicide exposure, as long as there is proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043 1044 (Fed. Cir. 1994). In a September 2014 statement, the Veteran reported that in the fall of 2011 he noticed his eyelid drooping and a loss of strength in his upper arms and that he was diagnosed with myasthenia gravis by a private doctor in August 2012. Private medical records show that the Veteran began experiencing double vision in approximately 2004 and was treated with prism glasses. In July 2011, after a complicated surgery, he developed right eye droopiness that progressed over time with his double vision. Other medical records show that he reported experiencing upper extremity weakness which he also noticed in approximately 2011. In August 2012, records from Dr. P.P. show that the Veteran was diagnosed with myasthenia gravis. Other private medical records show that the Veteran continued to receive treatment for myasthenia gravis with extremely severely elevated acetylcholine receptor antibodies and negative chest imaging studies. The Veteran’s symptoms were mainly ocular except for reported fatigable extremity weakness in his upper extremities with excessive physical activities. The Veteran’s medical records indicate that he was diagnosed with myasthenia gravis in August 2012, 43 years after his discharge from active duty service, and began experiencing symptoms in approximately 2004. The Veteran’s private treatment records do not provide evidence of a nexus between the Veteran’s service, to include his presumed exposure to herbicide agents, and his current disabilities. The Veteran’s Service Treatment Records (STRs) are silent for diagnosis of myasthenia gravis, double vision, or eye droopiness. A September 1968 record shows complaints of weakness, tiredness, malaise, myalgia, low grade fever, and backache, however, a physical examination revealed nasal congestion only. The Veteran’s May 1969 separation examination was normal and showed no defects or diagnoses. In summary, the medical evidence of record does not show that the myasthenia gravis or its associated ocular symptoms began during service, have been continuously present since service, or is otherwise related to an in-service injury or disease, to include his presumed exposure to herbicide agents. Similarly, the Veteran does not report that he experienced any symptoms of myasthenia gravis, drooping eyelid, or double vision during service. While the Veteran believes his myasthenia gravis, drooping eyelid, or double vision are related to his active duty service, including his presumed exposure to herbicide agents, the Board reiterates that the preponderance of the evidence weighs against finding that an in-service injury, event, or disease related to the Veteran’s myasthenia gravis, drooping eyelid, or double vision occurred. The Board further notes that the preponderance of the evidence weighs against finding that the Veteran’s myasthenia gravis, drooping eyelid, or double vision began during service, as the Veteran complained of double vision in approximately 2004, 35 years after he separated from service, and was not diagnosed with myasthenia gravis until 2012, 43 years after his discharge from active duty service. The Veteran has not been provided a VA examination with respect to his claimed disabilities. However, VA need not provide an examination with respect to this claim. VA must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Veteran has provided no evidence beyond a bare assertion that his myasthenia gravis, or the associated drooping eyelid, or double vision, is related to service or his presumed exposure to herbicide agents. Here, the standards of McLendon are not met as there is no competent evidence indicating the Veteran’s myasthenia gravis, drooping eyelid, or double vision may be associated with his active service, including his presumed exposure to herbicide agents. The only suggestion of a link is the Veteran’s own assertion in the form of his claim and his representative’s argument, which does not require VA to provide a medical examination or opinion. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). The Veteran has provided a copy of a 2016 Board decision granting entitlement to service connection for myasthenia gravis, but Board decisions are not binding precedent. 38 C.F.R. § 20.1303. Of particular importance, the 2016 decision reveals very different facts and a medical opinion that the Veteran in that case had onset of symptoms of myasthenia gravis before separation from service. The record before the Board in this case does not contain any such competent lay or medical evidence indicating there may be onset of symptoms during service or any other relationship between myasthenia gravis and service, including herbicide agent exposure. The Veteran submitted a second decision in which the Board denied an earlier effective date for the grant of service connection for myasthenia gravis; however, the RO had granted service connection and the Board’s discussion was not a weighing of the evidence regarding nexus in that case. The Board is not here persuaded by either submission that a nexus does or could exist in this case. While the Veteran believes that his myasthenia gravis with drooping eyelid and double vision disabilities are related to his active duty service, he is not competent to provide a medical nexus opinion in this case. The question is medically complex, as it requires knowledge of the interaction between multiple body systems and the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, as there is no evidence of an in-service occurrence or a nexus between the Veteran’s myasthenia gravis, drooping eyelid, or double vision and his service, to include his presumed exposure to herbicide agents, service connection is denied.  J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Boal, 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.