Citation Nr: 21003908 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 11-32 834 DATE: January 25, 2021 ORDER Entitlement to service connection for folliculitis is granted. Entitlement to service connection for mouth sores is denied. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 26, 2016 is denied. Entitlement to a 10 percent disability rating for conjunctivitis and blepharitis with meibomianitis is granted. FINDINGS OF FACT 1. The weight of the evidence establishes that the Veteran’s folliculitis began during active service. 2. The evidence does not show that the Veteran has a current disability manifested by mouth sores at any time during the rating period on appeal. 3. Prior to September 26, 2016, the Veteran’s PTSD symptoms have resulted in occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. 4. The Veteran’s conjunctivitis and blepharitis with meibomianitis has been manifested by itchy eyes with crustiness and blurred vision in the morning throughout the period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for folliculitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for mouth sores have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Prior to September 26, 2016, the criteria for entitlement to a disability rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. 4. The criteria for an initial 10 percent rating, but no higher, for conjunctivitis and blepharitis with meibomianitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.16, 4.20, 4.75-4.79, Diagnostic Code 6018. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Army from March 1986 to December 1992 and from July 2006 to November 2007, including overseas service in Iraq. In December 2016, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. This case was most recently before the Board in January 2018, at which time the matters on appeal were remanded for additional development. The case has since returned to the Board for appellate consideration. The Board notes that there are private medical treatment records that may have been relevant to the Veteran’s claim that remain outstanding. Specifically, the record indicates the Veteran attended counseling sessions on a weekly basis at the Dearborn Vet Center, and that she received primary care through Dr. M.G. The Veteran had the opportunity on remand to provide VA authorization to obtain any outstanding records from these providers on her behalf but failed to return a completed VA Form 21-4142. In this regard, the Board notes that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA is only obligated to obtain records that are adequately identified and for which necessary releases have been submitted. 38 C.F.R. § 3.159 (c)(1). Therefore, as the Veteran has not adequately identified or authorized the release of any additional outstanding treatment records, the Board will proceed with adjudicating the claims on appeal based on the available evidence of record. Additionally, regarding the PTSD claim, at the 2016 hearing the Veteran expressly sought a 70 percent rating. As such is already in effect from September 26, 2016, the issue on appeal has been characterized as set forth above. In a June 2020 rating decision, the Regional Office (RO) granted the Veteran’s claim of service connection for irritable bowel syndrome, which the Board had remanded in January 2018. As this represents a full grant of the benefit sought, that issue is no longer on appeal and will not be discussed further herein. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. § §§ 1110, 1131; 38 C.F.R. § § 3.303 (a). Service connection may also be granted for any disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § § 3.303 (d). Generally, to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board notes that Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in disability. Therefore, in the absence of proof of a present disability upon which to predicate an award of service connection, there can be no valid claim. 38 U.S.C. § 1110, 1131; Degmetich v. Brown, 104 F.2d 1328, 1332 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § § 5107 (b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for folliculitis In this case, the Veteran contends that her folliculitis had its onset during active service. In a January 2009 statement, the Veteran wrote that she had experienced skin rashes since April 2007. During her December 2016 Board hearing, the Veteran described her condition as consisting of rashes and painful, itchy, burning bumps. She stated that the condition had its onset in April 2007, while she was serving in Iraq. She testified that she sought treatment from VA when she first returned home. At the outset, the Board notes that VA treatment records and a September 2008 VA examination report show the Veteran has been diagnosed with folliculitis during the period on appeal. The Board acknowledges that the June 2018 and August 2020 VA examiners did not find that the Veteran had a current outbreak of the condition, with the latter examiner noting that folliculitis had “resolved.” However, service connection may be granted upon competent evidence that a claimed disability existed at any time during the appeal period. McClain v. Nicholson, 21 Vet. App. 319 (2007). As the evidence shows the Veteran has been formally diagnosed with folliculitis during the period on appeal, the Board finds that the first requirement of service connection, a current disability, has been met. Further, the evidence shows the Veteran’s folliculitis had its onset during active service. The Veteran was afforded a VA general medical examination in September 2008. She reported a history of skin rash that started when she was serving in Iraq. The examiner noted that the Veteran was seen in the Detroit VA Medical Center’s Dermatology Clinic in March 2008, at which time she was started on doxycycline for treatment of folliculitis. The examiner further noted that the Veteran was treated with doxycycline from July 2007, prior to discharge form active service, to May 2008. Physical examination revealed a few scattered lesions on her upper arm, back, and face. The examiner diagnosed chronic folliculitis. The Veteran was afforded a VA skin diseases examination in June 2018. The examiner diagnosed folliculitis and gave April 2007 as the date of diagnosis. The Veteran reported that the condition would come and go randomly and run its course and resolve on its own. The examiner noted that there was no current outbreak of folliculitis during the examination. The Veteran was most recently afforded a VA examination in connection with her claim in August 2020. The examiner diagnosed dermatitis and folliculitis but found that the Veteran’s folliculitis had resolved. In an accompanying opinion, the examiner wrote, “Since her Tour of duty ended in November 2007, it is at [sic] likely as not that her skin condition incurred while in the military.” The examiner noted that the Veteran’s entrance examination in 2005 did not demonstrate she had a rash prior to active service, and she sought treatment only three months after discharge from service, when the condition was serious enough to be treated with topical steroids and antibiotics. Overall, based on the foregoing, the Board finds that the weight of the evidence establishes that the Veteran’s folliculitis had its onset during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The June 2018 VA examiner gave April 2007, prior to discharge from active service, as the date of onset. Additionally, the Veteran has consistently reported that her folliculitis started during active service. The Board finds the Veteran’s statements in this regard to be credible, as well as competent, as folliculitis is a condition capable of lay observation. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for folliculitis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for mouth sores The Veteran seeks service connection for a disability manifested by mouth sores, which she attributes to exposure to toxins during her active military service in Iraq. During her December 2016 Board hearing, the Veteran testified that she had mouth sores that were “like blisters but nothing would ever be in them or ooze out of them. They were just these blister like things that were in my mouth.” She described them as very painful and stated that they would “come and go” along with her skin rashes. She reported that sometimes the sores made it hard for her to eat and brush her teeth. Turning to the evidence, the Board notes that a March 2008 VA treatment note documented “oral mucosa—skin colored papule right buccal cheek.” The Veteran reported “oral bumps that ulcerate.” The record indicated she had seen an oral surgeon and was waiting on a biopsy by dermatology, though there is no indication a formal diagnosis was ever made. During a March 2013 VA skin diseases examination, the Veteran reported a history of sores in her mouth that would come and go. Physical examination of the mouth revealed no redness or active ulcers or sores. A May 2013 VA dental and oral conditions examination revealed no apparent lesions or pathologies. A June 2018 VA dental and oral conditions examination report documented a diagnosis of folliculitis, but no disability manifested by mouth sores. Indeed, in an accompanying opinion, the examiner noted that there were no objective findings of any skin or mouth sores on physical examination of the Veteran. The Veteran was most recently afforded a VA oral and dental conditions examination in connection with her claim in August 2020. The Veteran reported symptoms of pain and blisters that bleed in her mouth but denied having any blisters at the time of the examination. The examiner did not diagnose an oral or dental condition, noting that the Veteran’s claimed condition of mouth sores had “resolved.” In an accompanying opinion, the examiner noted review of the Veteran’s claims file, including STRs and post-service treatment records. The examiner acknowledged the March 2008 VA treatment note showing tentative diagnosis of mucocutaneous diseases. The examiner determined that the Veteran’s description appeared to be “possible mucocele,” however there were no lesions, blisters, or ulcers visible during the examination sufficient to identify a definitive diagnosis. Overall, after careful review of the evidence of record, the Board finds that the evidence does not establish that the Veteran has had a disability manifested by mouth sores during the period on appeal. 38 U.S.C. § 1110, 1131; Degmetich, 104 F.2d at 1332; Brammer, 3 Vet. App. at 225. While a March 2008 VA treatment note documented a skin colored papule on the right buccal cheek, the provider did not actually diagnose the Veteran with an oral condition. Subsequent VA treatment records and examination reports have been silent for objective evidence of a diagnosed disability manifested by mouth sores. The Board acknowledges the Veteran’s reports that the mouth sores she has experienced have been painful, at times interfering with eating and brushing her teeth. The Board may consider pain, alone, to be enough to establish a current disability; however, to be considered as such, the pain must rise to the level of functional impairment of earning capacity. See 38 C.F.R. §§ 3.102, 3.303; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); Wait v. Wilkie, No. 18-4349, 2020 U.S. App. Vet. Claims LEXIS 1609 (Aug. 26, 2020). The evidence does not establish, and neither the Veteran nor her attorney have alleged that the pain caused by her purported mouth sores have risen to a level of functional impairment of earning capacity. Accordingly, service connection is not warranted. 38 C.F.R. §§ 3.303 Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. A Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 3. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 26, 2016 The Veteran asserts that she is entitled to a rating in excess of 50 percent for her service-connected PTSD for the period starting May 5, 2010. Under VA’s General Rating Formula for Mental Disorders, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. The maximum 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Further, simply because the Veteran has some symptoms that are contemplated at a higher rating level does not mean the impact of his psychiatric disability overall rises that level. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Instead, the Board must look to the frequency, severity, and duration of the impairment. Turning to the evidence, of record is an April 2008 letter from licensed clinical social worker T.E., the Veteran’s therapist at the Dearborn Vet Center. T.E. wrote that the Veteran had been enrolled in readjustment counseling services at the Dearborn Vet Center, and that she reported depression, bizarre nightmares, insomnia, severe hypervigilance, panic attacks, and exaggerated startle response to loud stimuli. She reported mistrust of others and suspicion of their motives related to incidences of harassment in the military. Also of record is an August 2008 statement from private Dr. J.G. regarding the Veteran’s ability to work for the railroad in light of her PTSD. Dr. J.G. wrote that the Veteran exhibited depressed mood and affect and experienced flashbacks and nightmares. Dr. J.G. concluded that the Veteran could not work in her last occupation without restriction because her symptoms of depression interfered with her daily functioning. The Board notes that the Veteran is in receipt of Social Security Disability benefits due to her PTSD. A psychiatric review completed in November 2008 in connection with her claim for Social Security Disability benefits includes information about the Veteran’s treatment at the Dearborn Vet Center. The examiner noted that the Veteran received readjustment counseling there with T.E. T.E.’s notes indicated the Veteran used book writing to ease her anxiety, and that she planned on using the G.I. Bill to attend college in the next year. She was noted to be on medical leave from her employer but was still attending drill with the National Guard, though she left a drill weekend early, purportedly due to harassment by the unit commander. She reported going on a family trip with her children, that she continued writing her book on her military experience, and that she planned to participate in a triathlon in Washington. The examiner obtained a statement from T.E. indicating the Veteran experienced at least one to two panic attacks per week. Overall, the Social Security examiner acknowledged the Veteran’s reports of increasing depression, anger, and insomnia, and ongoing daily flashbacks affecting her ability to resume her activities for an hour and sometimes more. The examiner also noted that the Veteran did not leave her house due to panic attacks, unless she could secure her environment. The Veteran was first afforded a VA mental disorders examination in March 2009. The examiner noted that the Veteran was not presently employed, having last worked as a railroad conductor from 2005 to 2006. The Veteran described her mood as angry, depressed, and frustrated since returning from Iraq. She denied current thoughts of self-injury, as well as any previous attempts to injure herself. She reported disturbed sleep but denied napping during the day. Her last nightmare was prior to the examination, and she reported having three in the previous seven days, one of which was about Iraq. The Veteran also reported general nightmares of people chasing her. At the time of the examination, the Veteran was divorced and living with three of her children. She reported being fully independent in all activities of daily living. However, one to two days per week she would stay in bed all day and not attend to much of anything. Most days she would get up, get her children ready for school, work out for an hour or so, then spend the day doing tasks around the home. She tried working on quilts but found her mind wandering. She reported having dinner with her children when they came home and would watch a movie or talk with them. The Veteran denied any contact with friends or family members and reported that when she needed to go to the store, she would take at least one of her children with her to decrease the likelihood of her panicking. She denied involvement in any civic or community organizations. The Veteran reported frequent difficulties with panic, citing a panic attack earlier on the day of the examination relating to stress from riding on the road. She had a friend bring her to her appointment because of her difficulties driving long distances due to panic. She reported awakening from sleep with a panic attack at times, and she reported having more panic attacks when outside her home. Regarding frequency, the Veteran reported that panic attacks happened daily, more than once daily, or they may not occur at all in a week. The Veteran further reported difficulty trusting and being around other people and had a lack of interest in engaging in most activities. She reported being jumpy from loud noises, easily agitated and frequently noticed her mind wandering. She reported some nightmares and intrusive memories of her in-service stressors. Hygiene and grooming were appropriate. Speech was fluent, logical, and goal directed. The Veteran was generally alert and oriented in all spheres. Attention, concentration, abstract reasoning, social judgment, and memory were all grossly intact. The Veteran denied experiencing hallucinations, delusions, and other psychotic symptoms, and not were evident on examination. The Veteran reported occasional flashbacks and periods of panic when she felt as though she was back in Iraq. Overall, the examiner found that the Veteran demonstrated mild to moderate impairment as a result of her PTSD symptoms. The examiner noted that she was not currently employed and that she reported ongoing problems while working as a result of the loud noises prompting elevated startle response. The examiner also noted that the Veteran reported some strain in her relationships with her older children and other family members, as well as her reports of general isolation and lack of friends and social involvement. The examiner further noted that the Veteran demonstrated some impaired mood, evidenced by irritability, depression, and general anxiety, and that she experienced “periodic” problems with panic attacks. In an April 2011 letter, Dr. M.G., the Veteran’s previous primary care provider, wrote that the Veteran’s PTSD caused panic attacks, anxiety, agoraphobia, and an eating disorder. Dr. M.G. further wrote that the Veteran’s depression was so severe that she wasn’t performing her daily activities because she was constantly reminded of her active duty service in Iraq. Dr. M.G. also wrote that the Veteran suffered nightmares so extreme it awakened her in sweats and rapid heartbeats causing her to have flashbacks related to Iraq. The Veteran was afforded another VA examination in April 2011. The Veteran reported increased difficulty leaving her house by herself and driving, as compared to the previous VA examination, but she reported that taking Xanax helped. She reported eating more when stressed and throwing up. She described some family stress. She reported having a good relationship with her daughters but stated that her son was angry over her past deployment. She reported spending her day doing house chores, watching TV, reading biographies, and watching movies. She reported that she continued to drill with the National Guard but that she missed three drill weekends in the last year because she did not like the military environment. On examination, the Veteran was clean and neatly groomed; psychomotor activity, thought process, thought content, and speech were unremarkable; she maintained a cooperative but guarded attitude toward the examiner; her mood was anxious; she was oriented to person, time, and place; she denied delusions; and judgment was intact. The Veteran reported sleep impairment, indicating that she would still wake up with nightmares, noises, and panic attacks, but she was able to sleep better with medication. She denied obsessive/ritualistic behavior. She reported panic attacks but indicated that Xanax helped control them. She denied suicidal or homicidal thoughts, and the examiner found no episodes of violence and no problems with activities of daily living. Remote, recent, and immediate memory were all normal. The Veteran endorsed PTSD symptoms of recurrent and intrusive distressing recollections of the stressful events. She also endorsed persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. She experienced difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance. She reported that the frequency of her symptoms had increased but medications helped her to “even out.” The Veteran reported a strained relationship with her son, lack of friends, sleep problems, and a dislike for the military environment. The examiner found that the Veteran’s PTSD symptoms resulted in occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, with generally satisfactory functioning (routine behavior, self-care, and normal conversation). The examiner opined that the Veteran’s PTSD symptoms had not increased in severity but had instead remained the same. Of record are treatment notes from counseling appointments the Veteran attended between March 2010 and December 2011 with Dr. S.M. The records document continued panic attacks, problems with crowds, and issues trusting other people. The Veteran frequently endorsed symptoms including anxiety, agoraphobia, irritability, frustration, depressed mood, and social phobia. In a February 2012 letter, the examiner’s Dearborn Vet Center therapist, T.E., wrote that the Veteran reported depression, insomnia, panic attacks, and exaggerated startle response to loud noises and exhibited severe hypervigilance regarding relationships. She appeared mistrustful of others and suspicious of their motives. T.E. further wrote that the Veteran’s mental capacity appeared to be exacerbated by past combat activity, promoting fear and panic, angry outbursts, intrusive thoughts, and inability to retain employment. T.E. indicated that the Veteran’s case was discharged in September 2011 “due to noncompliance with treatment.” During her December 2016 Board hearing, the Veteran testified that her PTSD had not worsened during the period from 2012 to 2016; that they had remained consistent. She reported that her therapist helped her with coping, and it became more of a struggle once the therapist went out of business. She reported attending school during that time, and that even though she attended school, it was a struggle to get up and go to school every morning, and sometimes she missed class. She testified that she did not really go anywhere and found it hard to drive, even opting to ride her bike back and forth to school. She testified that she would not go out in public without her service dog. In a May 2018 statement submitted in connection with her claim for a total disability rating based on individual unemployability (TDIU), the Veteran reported that she tried to return to her job at the railroad in January 2008, after returning from deployment. However, she was unable to do so because the training required exposed her to loud sounds that reminded her of mortars and rockets and would give her flashbacks to Iraq. She wrote that she was later given the opportunity to participate in VA’s vocational rehabilitation program, and that she studied fine arts in an attempt to find a job that she could do from home. However, she found college to be increasingly stressful and withdrew from classes in September 2016. Overall, after careful review of the evidence of record, the Board finds that the Veteran’s PTSD symptoms during the period prior to September 26, 2016 are best contemplated by the currently assigned 50 percent disability rating, and that a higher 70 percent rating for that period is not warranted. The weight of the competent and credible evidence shows that during the period on appeal, the Veteran’s PTSD caused occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks more than once a week, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating contemplates a more severe level of occupational and social impairment that is not demonstrated by the evidence in this case. The record does not show that the Veteran engaged in obsessional rituals which interfered with routine activities; that her speech was intermittently illogical, obscure, or irrelevant; or that she exhibited spatial disorientation or neglect of personal appearance and hygiene. The record is silent for reports of suicidal or homicidal ideation or intent. While the evidence indicates that the Veteran suffered from angry, irritable moods and anxiety with panic attacks at a frequency of more than once per week over the period on appeal, there is no evidence of near-continuous panic or depression affecting her ability to function independently, appropriately, and effectively. Critically, to the extent that symptoms more consistent with a 70 percent rating have been shown, the record fails to demonstrate that such symptoms have led to an overall level of social impairment contemplated by the 70 percent rating. For example, the Veteran had a good relationship with her daughters. Thus, she has not shown in an inability to establish and maintain effective relationships. The Board acknowledges that the Veteran was not employed during the period on appeal, which she attributed to her inability to handle the loud noises associated with working at the railroad and the flashbacks the noises would cause. The evidence also indicates the Veteran was unable to continue her National Guard service because her PTSD symptoms made it difficult for her to tolerate a military environment. However, the Veteran was able to attend school for much of the period on appeal, though her PTSD symptoms caused reduced reliability and productivity (as contemplated by her assigned 50 percent rating). While the occupational impairment is significant here, it has been contemplated by the award of a TDIU. Further, while the evidence shows the Veteran had difficulty maintaining social relationships during the period on appeal, it does not show that the Veteran was unable to establish and maintain effective relationships. The Veteran admitted to having few friends and reported a strained relationship with her son, but she reported having good relationships with her daughters during the period. As previously mentioned, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442-43. Further, simply because the Veteran has some symptoms that are contemplated at a higher rating level does not mean the impact of his psychiatric disability overall rises that level. Vazquez-Claudio, 713 F.3d at 117. Instead, the Board must look to the frequency, severity, and duration of the impairment. In this case, the Board finds that the frequency, severity, and duration of the impairment caused by the Veteran’s PTSD symptoms, as described above, are accounted for by the 50 percent disability rating assigned for the period. In reaching this conclusion, the Board acknowledges the Veteran’s attorney’s contention, made during the December 2016 Board hearing and reiterated in a May 2020 memorandum, that the 70 percent disability rating assigned from September 26, 2016 should be in effect for the whole period on appeal in large part because the Veteran’s symptoms were essentially unchanged and have been of the same severity throughout the period. However, this argument does not account for the Veteran’s symptoms during the period in the context of the relevant rating criteria. The May 2020 memorandum in particular contains no additional information or argument concerning the frequency, severity, and duration of the impairment caused by the Veteran’s PTSD that would clarify why a higher rating for that period is justified. Moreover, as previously mentioned, the Veteran has had the opportunity to provide additional evidence in support of her claim, but she did not respond to a request to identify or authorize the release of this evidence. Therefore, based on the foregoing, the assignment of a disability rating in excess of 50 percent for PTSD prior to September 26, 2016 is not warranted. 4. Entitlement to a 10 percent disability rating for conjunctivitis and blepharitis with meibomianitis The Veteran seeks a compensable rating for her service-connected conjunctivitis and blepharitis with meibomianitis, which is rated under 38 C.F.R. § 4.79, Diagnostic Code 6018, for chronic conjunctivitis. 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). 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 final rule went into effect May 13, 2018. Both the former and revised criteria provide for consideration of visual impairment. The amendments made no substantive changes to how visual acuity is rated. Regarding visual field and muscle function examinations, the Board notes that use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Under Diagnostic Code 6018, noncompensable evaluation is warranted for inactive chronic conjunctivitis, which is evaluated based on residuals of the condition, such as visual impairment and disfigurement. A 10 percent evaluation is warranted for active chronic conjunctivitis with objective findings of symptoms such as red, thick conjunctivae or mucous secretion. 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. 38 C.F.R. § 4.75 (b). 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. Visual impairment may also be rated based on impairment of visual field (Diagnostic Code 6080) and impairment of muscle function (Diagnostic Code 6090). Additional ratings may also be warranted for incapacitating episodes. However, as discussed below, the evidence does not show that the Veteran has had incapacitating episodes or visual field defects due to her service-connected conjunctivitis and blepharitis with meibomianitis. The Veteran can also be evaluated under Diagnostic Code 7800 for disfigurement, although the medical evidence of record does not reveal that this is for application under the facts of this particular case. Turning to the evidence, a March 2008 treatment record shows that the Veteran complained of itchy eyes with a rash around the eyes off and on ever since onset in Iraq in April 2007. She reported crusty lids in the morning, constant itching, and burning and watery eyes that interfered with daily living. The Veteran was first afforded a VA examination in connection with her claim in November 2008. She reported irritation of the eyelids, which started as a rash around both eyes, lasting around two to three weeks. She also reported blurry vision “at times.” The Veteran reported performing warm compresses with lid scrubs and baby shampoo twice daily to relief, with ointment three times daily in each eye, which relieved irritation and itch. Corrected distance and near visual acuity was 20/20 in both eyes. Lens examination showed trace blepharitis and conjunctivitis in both eyes. The Veteran was afforded another VA eye examination in September 2016. The examiner wrote that the Veteran reported having itchy, irritated, dry eyes beginning in 2008, which were treated with various eye drops. Corrected near and distance acuity was 20/40 or better in each eye. There was no loss of visual field. The examiner found that the Veteran had bilateral dry eye syndrome that was unrelated to the Veteran’s service-connected blepharitis. Of the blepharitis, the examiner wrote that it “tends to heal on its own” and “there were no complaints as such and not findings on exam to warrant continuing the diagnosis.” The Veteran was most recently afforded a VA examination in May 2018. The examiner diagnosed chronic meibomianitis and blepharitis in both eyes. Corrected near and distance visual acuity was 20/20 or better in both eyes. There was no visual field defect. The examiner found no decrease in visual acuity or other visual impairment. There was no scarring or disfigurement and no incapacitating episodes related to any eye condition over the previous 12 months. The examiner found that the Veteran’s eye disability did not impact her ability to work. The examiner determined that the Veteran did not have active conjunctivitis at the time of examination but noted that the Veteran’s blepharitis was responsible for her symptoms of itchy, watery eyes and blurred vision in the morning. VA treatment records show the Veteran continued to complain of crusty, matted discharge in both eyes throughout the period on appeal, for which she was treated with eye drops and artificial tears. During her December 2016 Board hearing, the Veteran testified that she experiences crustiness around the eyes every morning, sometimes with blurry vision and burning that necessitated walking around all day with wet tissues to keep them from hurting. She testified that she is unable to wear contacts due to the condition and puts eye drops into her eyes upwards of four times per day. She also reported that she had to start wearing glasses due to problems with both near and far vision. Overall, after careful review of the evidence of record, the Board finds that the Veteran is entitled to an increased 10 percent disability rating for her service-connected conjunctivitis and blepharitis with meibomianitis for the entire period on appeal. As discussed above, evidence from throughout the period on appeal shows that the Veteran’s disability has manifested in red, dry, and itchy eyes with crustiness and blurred vision in the morning, which is indicative of an active disease process. A 10 percent evaluation is the maximum rating warranted for active chronic conjunctivitis with objective findings of symptoms such as red, thick conjunctivae or mucous secretion. 38 C.F.R. § 4.79, Diagnostic Code 6018. In this regard, the Veteran’s claim for an increased rating is granted. However, a higher disability rating is not warranted because the evidence does not show visual impairment, incapacitating episodes, or other residuals. In this regard, the Veteran’s claim is denied. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. T. Raftery, 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.