Citation Nr: 21062075 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-47 751 DATE: October 6, 2021 REMANDED Entitlement to service connection for a bilateral foot condition, to include as due to service in the Gulf War, is remanded. Entitlement to service connection for a bilateral eye condition, to include as due to service in the Gulf War, is remanded. Entitlement to service connection for a head injury, to include as due to service in the Gulf War, is remanded. REASONS FOR REMAND The Veteran had active duty service from April 1980 to June 1980, from June 1981 to July 1981, and from November 1990 to August 1995. The Veteran also had service in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2021 written correspondence, the Veteran requested that his hearing be cancelled. Therefore, the Veteran's hearing request is deemed withdrawn. 38 C.F.R. § 20.704 (d). The Board notes that in February 2018 correspondence, the Veteran submitted a Freedom of Information Act (FOIA) request which has not been addressed. Since the Veteran's claims are being remanded for additional development, the Veteran's FOIA request can be addressed while on remand, therefore; the Veteran will not be prejudiced. 1. Entitlement to service connection for a bilateral foot condition, to include service in the Gulf War, is remanded. The Veteran contends he has a bilateral foot condition due to service in the Gulf War. In a July 2017 VA skin examination, the Veteran was diagnosed with tinea pedis of the foot bilaterally; however, the examiner found that the condition was not related to service since reputable literature does not support exposures from Southwest Asia as a cause. The Board finds this opinion is inadequate as the examiner merely provided a general conclusory statement without any additional medical rationale. In addition, the examiner did not consider the lay statements of record. Specifically, the Board observes statements from the Veteran's wife in February 2016 and April 2018 in which she reported that the Veteran has had reoccurring blisters on his feet since returning from the Gulf War, and that he did not have these prior. In addition, the Veteran reiterated the same in his September 2017 substantive appeal (Form 9). The Board notes that lay statements must be considered by VA examiners in formulating their medical opinions; otherwise, the examinations are inadequate. Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). Therefore, since the examiner failed to consider the lay statements of record and support the opinion with medical rationale, remand is warranted to obtain a new examination and opinion. 2. Entitlement to service connection for a head injury, to include service in the Gulf War, is remanded. The Veteran contends service connection is warranted for a head injury he sustained in service. Specifically, in an April 2017 Report of General Information, he contended that he suffered from hydrocephalus from hitting his head while jumping in fox holes and from explosions. In a July 2017 medical opinion, the examiner found that hydrocephalus is less likely than not related to the Veteran's service in Southwest Asia. The examiner found that reputable literature does not support Southwest Asia exposures causing hydrocephalus. However, the Board finds this opinion is inadequate based on the examiner's general conclusion without any supporting medical rationale. In addition, the examiner did not consider the Veteran's reports of how he purportedly injured his head in service. As noted above, the examiner must consider the Veteran's lay statements in the rendered opinion. In addition, the Board notes that the Veteran is competent to report an injury in service and the Board finds him credible in this regard. Therefore, since the examiner did not support the opinion with medical rationale and failed to consider the Veteran's lay statements, remand is warranted to obtain a new examination and opinion. 3. Entitlement to service connection for a bilateral eye condition, to include service in the Gulf War, is remanded. The Veteran seeks service connection for a bilateral eye condition. In the July 2016 rating decision, the RO denied service connection on the basis that defects of form or structure of the eye that are congenital or developmental in origin may not be considered as disabilities or service connected on the basis of incurrence of aggravation beyond natural progress during service. The RO specifically noted that the Veteran's diagnosis of monocular exotropia, which the RO referred to as lazy eye, was noted on the Veteran's entrance examination and is considered to be a congenital or development disability. The Board notes, however, that medical literature seems to suggest that the conditions of exotropia and lazy eye are not one and the same. See https://optometrists.org/staging/what-is-strabismus-vs-amblyopia-treatment. In this regard, the Board notes that the Veteran's March 1980 enlistment examination is silent for an eye disability; however, a September 1986 medical examination shows a notation for right exotropia, and a September 1998 examination shows a notation for right lazy eye. Additionally, in an April 2017 Report of General Information, the Veteran reported that he was not born with the condition of lazy eye and that his insurance approved and paid for corrective surgery. Given these findings, the Board finds an examination is warranted to determine the nature and etiology of the Veteran's eye disabilities. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims folder. 2. Undertake appropriate development to obtain any outstanding private treatment records related to the Veteran's disabilities being remanded. The Veteran's assistance should be requested as needed. All obtained records should be associated with the evidentiary record. If the AOJ cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 3. Schedule the Veteran for VA examinations with a qualified clinician to determine the etiology of the Veteran's bilateral foot, head, and bilateral eye disabilities. The examiner must review the claims folder, including a copy of this remand and all lay statements of record. Then the examiner should provide an opinion as to the following: BILATERAL FOOT: Provide an opinion as to whether the Veteran has a right and/or left foot disability that is at least as likely as not (50 percent probability or greater) related to service, to include service in the Gulf War. HEAD INJURY/CONDITION: Provide an opinion as to whether the Veteran has a head disability, to include hydrocephalous, that is at least as likely as not (50 percent probability or greater) related to service, to include service in the Gulf War. BILATERAL EYE: (a) Identify all currently diagnosed eye disabilities of record. (b) Determine whether there is clear and unmistakable evidence that any identified eye condition pre-existed service. (c) IF THE CONDITION PRE-EXISTED ACTIVE DUTY SERVICE, is there clear and unmistakable evidence that the condition was NOT aggravated (permanently worsened) beyond the natural progression as a result of a period of active duty, active duty for training (ACDUTRA), or by any injury sustained during a period of inactive duty for training (INACDUTRA). (d) IF THE CONDITION DID NOT PRE-EXIST A PERIOD OF ACTIVE SERVICE, is it at least as likely as not (a 50% or greater probability) that the disability had its onset during active service or is otherwise related to active service, OR that the disability was caused or permanently aggravated (permanently worsened) beyond the natural progression as a result of a period of ACDUTRA or by any injury sustained during a period of INACDUTRA. The examiner should provide a complete rationale for any opinions expressed. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. 4. The RO must review the examination reports and all opinions to ensure they are complete, adequate, and comply with the Board's specific remand directives. 5. Then re-adjudicate the claims. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Laffitte, 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.