Citation Nr: 21061623 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 16-14 609 DATE: October 4, 2021 REMANDED The issue of service connection for an eye condition is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1965 to February 1967. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by the RO. In a June 2020 decision, the Board denied the claim on appeal. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In June 2021, the Court granted the parties' May 2021 Joint Motion for Remand (JMR) and vacated and remanded the Board's June 2020 decision. Specifically, the parties agreed that remand was warranted because the Board erred when: (1) it failed to ensure substantial compliance with its October 2018 remand directives see Stegall v. West, 11 Vet. App. 268, 271 (1998) and (2) it did not ensure that VA complied with its duty to assist when it failed to attempt to obtain private treatment records related to the Veteran's eye condition. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). 1. The issue of service connection for an eye condition is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends that his eye condition was caused by his military duties of welding and using a cutting torch, plus exposure to exhaust and back firing from mechanical work. He also argues an in-service brain concussion could have caused the current eye condition. In the October 2018 remand, the Board instructed the RO to schedule the Veteran for VA examination to determine the etiology of his current eye disabilities. Specifically, the examiner was to identify each eye disability that had been manifest or diagnosed since May 2015 and for each diagnosed disability, the examiner was asked whether it was at least as likely as not that the disability was incurred during service or otherwise related to service. The examiner was asked to consider all the lay and medical evidence of record, including the Veteran's assertions that his current disabilities were incurred because of his military duties as a mechanic or in the alternative, the concussion he incurred in June 1965. In the July 2019 VA examination report, the optometrist opined that the claimed eye condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran's dry eye syndrome and cataracts were part of normal aging processes. Considering the parties May 2021 JMR, the Board finds the examination is insufficient for determining whether service connection may be granted. The optometrist did not provide a medical explanation or rationale to support her conclusion (that the claimed eye condition was less likely than not incurred in service because the Veteran's dry eye syndrome and cataracts were normal aging processes) and did not address the Veteran's assertions (that his current disabilities were incurred because of his military duties as a mechanic or in the alternative, the concussion he incurred in June 1965). In addition, the optometrist did not provide an etiology opinion of all diagnosed eye disabilities, namely intraocular lens. THE REMAND DIRECTIVES FOLLOW. 2. Request that the Veteran provide the names and addresses of all health care providers who have provided treatment for his eye disabilities whose records have not been obtained. Advise the Veteran to sign the appropriate authorization forms. Obtain and associate any outstanding pertinent records with the electronic claims file. 3. Schedule the Veteran for VA eye conditions examination to determine the etiology of his claimed eye disabilities. The claims file should be made available to the ophthalmologist or optometrist for review. All appropriate tests should be accomplished and all clinical findings should be reported in detail. The ophthalmologist or optometrist should address the Veteran's documented medical history and assertions the Veteran asserts that his eye condition onset due to welding and using a cutting torch, plus exposure to exhaust and back firing from mechanic work during his period of service. In the alternative, he asserts that an in-service brain concussion could have caused the current eye condition. After reviewing the entire record, the ophthalmologist or optometrist MUST provide an opinion with supporting explanations as to the following: Does the Veteran have current eye disabilities that had onset due to disease or injury sustained during his period of service? The examiner must fully explain WHY or WHY NOT he or she provides the response to this question. The ophthalmologist or optometrist must discuss whether the Veteran's account of the development of the claimed eye disabilities is consistent with the medical evidence and the ophthalmologist or optometrist knowledge and practice experience. As indicated above, the ophthalmologist or optometrist must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *March 1965 service treatment record Report of Medical History associated with his enlistment examination documents the Veteran's report that he had a brain concussion that caused his left ear to go bad. *April 1965 service treatment record skull x-ray findings were normal. The Veteran reported that he was struck on the left side of his head on the temporal frontal area. He complained of pain and left sided tinnitus since the accident. *June 1965 service treatment record reflects that the Veteran sustained an injury to the left side of his head during civilian life after being struck by a board. He complained of headache and dizziness. On examination the impression was posttraumatic headaches. *June 1965 service treatment record reflects that the Veteran received treatment for post-concussion syndrome with anxiety state and left ear sensorineural hearing loss. The Veteran reported that he had a history of head trauma sustained in September 1964. *July 2014 VA treatment record documents the Veteran's complaint of left eye irritation due to his lashes rubbing. On examination, the impression was mild senile cataracts and mild entropion of the left lower lid (LLL) status post repair of spastic entropion LLL in October 2009. *January 2015 VA eye clinic treatment record reflects the Veteran received follow-up treatment for his senile cataracts and mild entropion of LLL. The Veteran reported that he always felt like he had something in his right eye but his left eye was better since surgery. On examination, the impression was mild senile cataracts, status post repair of spastic entropion LLL in October 2009 and 2014 and significant, bilateral senile ptosis. *July 2015 private treatment record reflects that the Veteran was admitted on an outpatient basis for bilateral blepharoplasty of the upper eyelids. *July 2019 VA eye conditions examination report documents diagnoses of presence of intraocular lens; age-related nuclear cataract of the left eye; and dry eye syndrome of bilateral lacrimal glands. The Veteran reported that his eyes have been itchy and irritated since approximately 1993. He used eye drops as needed and underwent blepharoplasty in 2015 to help with eyelashes that were poking and irritating his eyes. that the Veteran has a bilateral hearing loss disability for VA purposes. The optometrist opined that the claimed eye condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran's dry eye syndrome and cataracts were normal aging processes. A thorough explanation must be provided for the opinion rendered. If the ophthalmologist or optometrist cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why opinions cannot be made without resorting to speculation. (CONTINUED ON NEXT PAGE) THE OPHTHALMOLOGIST OR OPTOMETRIST IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE ELECTRONIC FOLDER CONTAINING THE EVIDENCE WAS REVIEWED AND/OR THE OPHTHALMOLOGIST OR OPTOMETRIST HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's actions are binding only in this case and do not establish precedent or establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.