Citation Nr: 21004511 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 18-47 866 DATE: January 27, 2021 REMANDED Entitlement to service connection for a right eye disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1962 to November 1965. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a right eye disability. The Board notes that the Veteran was scheduled for a virtual hearing in January 2021. However, the claims file reflects that the Veteran cancelled the hearing. Accordingly, the Board deems the hearing request withdrawn. 38 C.F.R. § 20.704(e). Entitlement to service connection for a right eye disability is remanded. The Veteran contends that his current right eye disability is related to an eye injury he sustained during active service. See October 2017 Statement in Support of Claim; see also May 2018 Veteran’s correspondence. A March 1963 entry in the Veteran’s service treatment records (STRs) noted that the Veteran was struck with another person’s head just above the right eye, resulting in a laceration which was treated with sutures. See March 20, 1963 Chronological Record of Medical Care. Another March 1963 entry in the Veteran’s STRs noted that the “laceration of [the] eyelid [was] healing well.” The Veteran was scheduled for a follow-up appointment for suture removal. See March 23, 1963 Chronological Record of Medical Care. A third March 1963 entry in the Veteran’s STRs noted that the stitches were removed with good healing. See March 26, 1963 Chronological Record of Medical Care. A September 1963 entry noted that the Veteran sustained several small lacerations of the forehead and nose after bumping into a light, for which he received sutures. See September 13, 1963 Chronological Record of Medical Care. An October 1963 entry noted the Veteran’s complaints that light caused his right eye to burn and interfered with his duty. See October 9, 1963 Chronological Record of Medical Care. The Veteran was afforded a VA examination in February 2017. The examiner noted diagnoses of bilateral primary open angle glaucoma, cataracts, presence of intraocular lens, and right eye conjunctival nevus. The Veteran reported that he injured his head during active duty, which resulted in stitches above both eyebrows. He reported that when he returned to work, lights bothered him. As a result, he went to see the medic twice. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran’s right eye. The examiner opined, The veteran had trauma to the area above his eyebrows, he had sutures to the eyebrow area, no sutures to the eyelids themselves. Review of STR shows that veteran did not see an eye care specialist during or after his injury in 1963. The notes show that sutures were placed and then removed. There are no notes in STR stating any vision problems after the sutures were removed. The Board finds that the VA examination is inadequate, as the examiner’s opinion is based, in part, on an inaccurate factual premise, namely that there were no notes in the Veteran’s STRs indicating vision problems after his sutures were removed. In that regard, the examiner failed to address the significance, if any, of the October 1963 entry in the STRs noting the Veteran’s complaints that light caused his right eye to burn and interfered with his duty. As such, an addendum medical opinion is warranted. Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum medical opinion regarding the nature and etiology of the Veteran’s current right eye disability. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the opinion. After reviewing the record, provide an opinion, with supporting rationale, as to the following: (Continued on the next page)   Is it at least as likely as not that the Veteran’s current right eye disability had its inception during his period of active service or is otherwise causally related to an in-service disease or injury, to include a March 1963 laceration above the right eye and/or lacerations to the forehead and nose sustained in September 1963? A complete explanation must be provided for any opinion offered. In providing the requested opinion, the examiner should reference any relevant evidence of record, to include the Veteran’s STRs which noted the Veteran’s complaints in October 1963 that light caused his right eye to burn and interfered with his duty. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.