Citation Nr: 21061975 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 18-35 922 DATE: October 6, 2021 REMANDED Entitlement to service connection for left eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 27, 1962 to August 20, 1962. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2015 by a Department of Veterans Affairs (VA) Regional Office. In September 2021, the Veteran testified at a Board hearing before the undersigned. The case is being rendered under the Board's One-Touch Initiative. The Board also notes that the Agency of Original Jurisdiction characterized the issue on appeal as an application to reopen a previously denied claim for service connection. In this respect, the record reflects some conflict concerning the filing of a timely notice of disagreement by a private attorney subsequent to the September 2015 rating decision. Given the confusion regarding representation, and the Veteran's submission of a request for reconsideration and VA Form 21-526EZ within the one-year appeal period, the Board finds the Veteran has continuously pursued his claim since the receipt of his initial service connection claim on May 21, 2015. Thus, the issue has been characterized herein accordingly. The Veteran contends he has a current left eye disorder, resulting in a loss of sight, that is directly related to in-service treatment. In the alternative, the record suggests that a left eye disorder pre-existed service and, thus, raises the theory that service may have aggravated a pre-existing left eye disorder. Specifically, the Veteran's July 1962 entrance examination indicates he had defective vision in his left eye, and according to a July 1962 report of medical history, the Veteran had a history of wearing glasses and a left eye fungus. According to an August 1962 clinical record, the Veteran complained of pain in the left eye with blurring vision and reported trouble with his eyes for the past three years. The record indicates an eye specialist had previously treated the left eye and kept the condition from worsening; however, since entering the service, the Veteran stated that his left eye had been giving him more trouble, which is why he reported to sick call for treatment. Physical examination at that time revealed a round area of an old scarred corneal ulcer with deep corneal round infiltrates, which appeared typical of a fungus infection, and the clinician provided a diagnosis of chronic corneal ulcer of the left eye due to a fungus, probably actinomycosis, that existed prior to service. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). As the Veteran's entrance examination notes defective vision in the left eye, the presumption of soundness is inapplicable in the instant case. Where a pre-existing disease or injury is noted on the entrance examination, 38 U.S.C. § 1153 provides that such will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). In connection with his appeal, the Veteran underwent VA examination in July 2015, and in the associated medical opinion, the VA examiner opined the claimed left eye condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner found relevant that the record documented the Veteran's reports of treatment for a fungal infection of the cornea in the left eye three years prior to the August 1962 examination, which had a high risk for causing vision loss. The VA examiner also noted there was no documentation of the administration of eye drops on examination in July 1962 or August 1962. Upon review, the Board finds the medical opinion insufficient for the purpose of determining service connection. In particular, the VA examiner did not address whether the pre-existing left eye disorder underwent an increase in disability during service and, if so, whether such was due to the natural progress of the disease. As a result, the Board finds remand is warranted for an addendum opinion addressing such matters. The matter is REMANDED for the following action: Forward the record and a copy of this Remand to an appropriate clinician for an addendum opinion. The need for additional examination is left to the discretion of the clinician. Following a review of the record, the clinician should address the following inquiries: (A) Was there an increase in the Veteran's chronic corneal ulcer in the left eye during service? (B) If so, was such increase due to the natural progress of the disease? In addressing such inquiries, the clinician must address the Veteran's statements concerning his in-service symptomatology, to include his reports that eye drops administered during service resulted in burning symptoms, blurriness, and vision loss. A rationale should be provided for any opinion offered. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. M. Celli, 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.