Citation Nr: 21005074 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 18-30 217 DATE: January 28, 2021 REMANDED Entitlement to a rating higher than 60 percent for right eye enucleation and left lens removal is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1966 to April 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). In February 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In July 2020, the Board remanded the case for additional development. The Board observes that since the issuance of the November 2020 supplemental statement of the case updated VA treatment records have been associated with the file. The Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence. However, the Board finds that since the claim is being remanded, the AOJ will have the opportunity to review it in the readjudication of his claim. Therefore, no prejudice results to the Veteran in the Board considering such evidence for the limited purpose of issuing a comprehensive and thorough remand. Entitlement to a rating higher than 60 percent for right eye enucleation and left lens removal is remanded. The Veteran contends that his bilateral eye disability is more severe than his current rating. At the February 2020 hearing, the Veteran reported that he has blepharitis, floaters, conjunctivitis, and macular degeneration. VA treatment records show diagnoses for blepharitis. In August 2020, the Veteran’s annual VA eye examination also showed a diagnosis for blepharitis with dry eyes. The Veteran attended a VA examination for the bilateral eye disability in October 2020. The examiner diagnosed right eye enucleation and left eye pseudophakia. The eye conditions Disability Benefits Questionnaire (DBQ) report instructs the examiner to complete the relevant sections pertaining to the applicable diagnoses. However, the examiner did not complete the cataract section of the examination report. In addition, the October 2020 VA examiner found there was no blepharitis, conjunctivitis or infection on examination. The examiner further stated that there was no impairment because the conditions could be treated with medication. The Board notes that the examiner did not provide an etiology opinion on blepharitis. For these reasons, the Board finds the October 2020 examination incomplete. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, remand is required to obtain updated treatment records and provide the Veteran with updated an VA examination that evaluates the current symptomatology. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records from December 2020 to the present. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA eye examination to determine the current nature and severity of service-connected right eye enucleation and left eye pseudophakia. The examiner must review the claims file and should note that review in the report. Any and all studies or tests deemed necessary should be performed. The examiner should elicit information about the nature of the eye disability and all symptoms or manifestations of the disability when present, even if not present at the time of the examination, including dry eye, floaters, blurriness, itchiness, dizziness, and light-headedness. The examiner should specifically address whether the Veteran’s blepharitis, conjunctivitis or infection is the result of his right eye enucleation and left lens removal. The examiner must address the Veteran’s lay statements regarding other eye impairment such as drainage, eye socket issues, blepharitis, conjunctivitis, and macular degeneration. To the extent possible, the examiner should comment on the Veteran’s incapacitating episodes during the appeal period. The examiner should consider all applicable versions of the pertinent eye rating criteria during the appeal period (including the versions of the eye rating criteria effective prior to May 13, 2018, and since May 13, 2018). A complete rationale for any opinion expressed should be provided. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Kass, 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.