Citation Nr: 21061315 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 04-38 503A DATE: October 1, 2021 REMANDED Entitlement to service connection for residuals of bilateral eye injury other than posterior vitreous detachment (PVD) is remanded. Entitlement to an initial disability rating in excess of 10 percent for bilateral vitreous detachment (claimed as bilateral eye injury) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1980 until his honorable discharge in October 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from the January 2003 and January 2018 rating decisions by the St. Petersburg, Florida Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a November 2007 decision, the Board denied the Veteran's claim for entitlement to service connection for bilateral eye disorder claimed as the residuals of an eye injury. The Veteran subsequently appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2009 Joint Motion Partial Remand (Motion), the Court remanded the case to the Board for further consideration. In December 2009, March 2012, and May 2015, the Board remanded the case to the RO for further development. Specifically, the most recent Board remand directed the RO to obtain any private treatment records related to the Veteran's eyes that are not already of record and to afford the Veteran with a VA examination for his eye disabilities. 1. Entitlement to service connection for residuals of bilateral eye injury other than vitreous detachment is remanded. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Throughout the period on appeal, the Veteran has had numerous VA examinations and private evaluations. Specifically, November 2002, April 2010, October 2012, July 2016, November 2016, December 2017, and February 2020. During the November 2002 VA examination, the Veteran reported that he had bilateral floaters with no history of other eye problems other than being near sighted. The examiner found that the Veteran's (corrected distance) visual acuity was 20/25 bilaterally. During the April 2010 VA examination, the Veteran reported irritated eyes with blurred vision and floaters in the left eye and a history of dry eye syndrome. The April 2010 VA examiner noted that the Veteran has previously been treated for multiple bouts of blepharoconjunctivitis of the left eye and has had several surgical removal of eyelid and conjunctival growths which were reported as benign and continued treatment of eyedrops and ointment bilaterally. Finally, the April 2010 VA examiner found that the Veteran's corrected distance visual acuity was 20/20 bilaterally with minimal cataracts of the left eye with a history of dry eye syndrome without substantiation by a Schirmer tear test. During the June 2012 VA examination, the Veteran was diagnosed with dry eye syndrome and peripheral vitreous detachment. The Veteran reported that his astigmatism is getting worse and he is having aching pain in the left eye. Furthermore, the Veteran reported that his floaters were more prevalent. The June 2012 VA examiner found that the Veteran had corrected distance visual acuity of 20/40 bilaterally without visual field defects but did have dry eye syndrome (confirmed by Schirmer tear test), bilateral faint arcus senilis, bilateral vitreous syneresis with floaters, bilateral preoperative cataracts. During the July 2016 VA examination, the Veteran was diagnosed with peripheral vitreous detachment and the Veteran reported that he has had dry eye syndrome since service and it has progressively worsened since service, which was diagnosed in 2004 by a private provider. The July 2016 VA examiner found that the Veteran had corrected distance visual acuity of 20/40 or better bilaterally without a visual field defect but with bilateral conjunctivitis (pinguecula) that does not produce a decrease in the Veteran's visual acuity or other visual impairment and noted that the Veteran's dry eye syndrome produces blurry vision. The July 2016 VA examiner also found that the Veteran has bilateral mild preoperative cataracts that produce blurry vision. The Veteran reported that he was suffering from bilateral dry eye, bilateral cataracts, bilateral histoplasmosis, bilateral meibomian gland dysfunction, and upper lid scar. During the November 2016 VA examination, the examiner found that the Veteran did not have a visual field defect, but also noted that the Veteran had a superior contraction of the visual field in the left eye. During the January 2020 VA examination, the Veteran was diagnosed with bilateral posterior vitreous detachment and bilateral preoperative cataracts. The Veteran reported that the Veteran complained of floaters and blurry vision with glasses (3 years old). The January 2020 VA examiner found that the Veteran's corrected distance visual acuity was 20/20 or better without a visual field defect. Within an August 5, 2020 correspondence from the Veteran's attorney, the Veteran's attorney asserted that the Veteran has been diagnosed with various eye disabilities, including myopia, astigmatism, presbyopia, amblyopia, blepharitis, conjunctivitis, dry eyes, glaucoma, and posterior vitreous detachment. The Veteran's attorney correctly notes that none of the previous VA examiner's provided nexus opinions nor rationales for all of the Veteran's eye disabilities. Furthermore, generally speaking when a nexus opinion was provided, it did not include a detailed rationale explaining the opinion provided. The Board notes that the last private treatment records received were in February 2016. A remand is required to allow VA to obtain authorization and request updated treatment records, if any exist. The Board notes that the last VA treatment records received were for the period ending January 16, 2018. Any VA treatment records are within VA's constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain updated VA treatment records. For the above reasons, remand is required. 2. Entitlement to an initial disability rating in excess of 10 percent for bilateral vitreous detachment (claimed as bilateral eye injury) is remanded. Finally, because a decision on the remanded issue of entitlement to service connection for residuals of bilateral eye injury other than vitreous detachment could significantly impact a decision on the issue of entitlement to an initial disability rating in excess of 10 percent for bilateral vitreous detachment (claimed as bilateral eye injury), the issues are inextricably intertwined. Therefore, a remand of the claims for entitlement to an initial disability rating in excess of 10 percent for bilateral vitreous detachment (claimed as bilateral eye injury) is required. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any private treatment records not already of record pertaining to his eye disabilities. Make two requests for the authorized records from the Veteran's private provider(s), unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA treatment records for the period from January 17, 2018 to present and any other VA treatment records that are not already of record. 3. After the above has been completed, schedule the Veteran for a VA eye examination for his claims of entitlement to service connection for residuals of bilateral eye injury other than vitreous detachment and entitlement to an initial disability rating in excess of 10 percent for his bilateral vitreous detachment (claimed as bilateral eye injury). The examiner must review the claims file, including a copy of this remand. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Identify all eye disabilities that the Veteran currently has and all eye disabilities that the Veteran has been diagnosed with throughout the period on appeal. If a diagnosed eye disability has resolved during the period on appeal, it must be identified and determined when it began and when it resolved. For each and every eye disability, the examiner must provide an opinion if the identified eye disability(ies) are at least as likely as not (50 percent probability or greater) related to his active military service, including but not limited to an in-service eye injury. Provide a detailed rationale to support any opinion(s) provided. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? For each and every eye disability, the examiner must provide an opinion if the identified eye disability(ies) are at least as likely as not (50 percent probability or greater) proximately due to a service-connected disability including but not limited to bilateral vitreous detachment? For each and every eye disability, the examiner must provide an opinion if the identified eye disability(ies) are at least as likely as not (50 percent probability or greater) aggravated, i.e., worsened beyond its natural progression, by a service connected disability? For each and every eye disability, the examiner must provide an opinion of the effects of the specific disability on the Veteran's visual acuity (corrected distance, visual field, etc.). If the examiner determines that the Veteran's visual defects are due to only congenital defects and/or disability(ies) unrelated to the Veteran's active military service, it must be clearly stated. The examiner must also provide opinion(s) on increases and decreases in severity of his eye disabilities during the period on appeal, differentiating and identifying the severity of disabilities associated with his active military service (including secondary and aggravated disabilities) as compared to the severity of disabilities that are not related to his active military service (excluding secondary and aggravated disabilities). If the examiner stated that an opinion could not be provided without resort to speculation, the examiner must explain the basis of the inability to provide the opinion and indicate if the speculation was due to lack of personal knowledge or lack of knowledge within the medical community. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Deemer, 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.