Citation Nr: 21062447 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 19-16 293 DATE: October 7, 2021 REMANDED Entitlement to service connection for a disability manifesting in transient vision loss of the right eye, to include ophthalmic migraines or retinal vasospasms, as secondary to service-connected macular atrophy, left eye (left eye disability) is remanded. Entitlement to a higher level of compensation for service-connected left eye disability, pursuant to the provisions of the paired organ rule under 38 C.F.R. § 3.383 is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1958 to August 1959. This case comes on appeal of a December 2017 rating decision. The Veteran testified before the Board at a September 2019 videoconference hearing. These matters have been before the Board on two previous occasions. Most recently, in February 2021, the Board remanded the claim for further development. Unfortunately, as will be discussed further below, additional remand is necessary to obtain an adequate medical opinion upon which an adjudication can be made. The Board also notes that, following its February 2021 remand, the agency of original jurisdiction (AOJ) issued an April 2021 supplemental statement of the case (SSOC) continuing the denial of entitlement to the issues below. In response, in May 2021, the Veteran submitted a request for higher-level review under the modernized appeals system. However, in a May 2021 letter, the AOJ notified the Veteran that it could not accept the Veteran's higher-level review application, as the time limit to file the application had passed. The Veteran has not appealed this decision by the AOJ, and the claim was subsequently recertified to the Board. Therefore, it remains on appeal under the legacy appeals framework at this time. 1. Entitlement to service connection for a disability manifesting in transient vision loss of the right eye, to include ophthalmic migraines or retinal vasospasms, as secondary to service-connected macular atrophy, left eye (left eye disability) is remanded. 2. Entitlement to a higher level of compensation for service-connected left eye disability, pursuant to the provisions of the paired organ rule under 38 C.F.R. § 3.383 is remanded. As the Board has discussed in its prior remands, the Veteran has a documented history of a right eye condition that manifests in transient partial or total vision loss. According to the Veteran's statements on examination and in the course of regular treatment, these episodes of vision loss can happen anywhere from three times per month to three times per week, and last approximately 30 to 60 minutes. The Veteran has presented two theories of contention regarding this disability. First, the Veteran contends that the right eye disability is caused or aggravated by his service-connected left eye disability. Examination records demonstrate that the Veteran has a macular scar of the left eye that had its onset in service. The Veteran's corrected left eye visual acuity is 5/200, indicating that he cannot see out of the left eye. The Veteran also contends that, in the absence of service connection on a secondary basis, his right eye vision loss should be considered in the evaluation of his left eye vision disability, pursuant to the paired organ rule under 38 C.F.R. § 3.383. Regarding the first theory of entitlement, in a September 2019 statement, the Veteran's optometrist, Dr. R.C., opined that the episodes of transient vision loss were not the result of the macular scar in the left eye. Rather, according to Dr. R.C., the most likely cause of the transient vision loss was ophthalmic migraines, caused by vasospasm. This was in contrast to a previous VA examination, which found that the Veteran's right eye condition was of unknown etiology. Based on this information, the Board remanded the claim in February 2021 to attempt to determine first, whether there was any reason to reject the theory that the Veteran's right eye condition was caused by ophthalmic migraines, and second, whether the Veteran's ophthalmic migraines and/or vasospasms were themselves caused or aggravated by the Veteran's left eye disability or its residual effects. In other words, the Board sought to confirm whether it was at least as likely as not that the right eye condition was, effectively, a symptom of a migraine condition or a vascular condition. If so, the Board sought to determine whether the migraine condition or the vascular condition was caused or aggravated by the Veteran's left eye disability or its residual effects. In February 2021, the Veteran underwent a VA eye conditions examination. There, the examiner opined that there was no medical reason to call into question Dr. R.C.'s assessment that the Veteran's episodic right eye blindness was a consequence of ophthalmic migraines caused by vasospasms. The Veteran then underwent a March 2021 VA headaches examination to address the etiology of his migraines. There, the examiner opined that it was less likely than not that the Veteran's ophthalmic migraines and/or vasospasms were proximately due to his service-connected left eye condition. However, by way of rationale, the examiner only stated that the Veteran's left eye condition occurred in 1957 and his right eye issues began in 1970. The examiner did not offer any explanation as to the medical significance of this information or how it informed the negative nexus opinion. Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). An adequate medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, the March 2021 examiner's opinion provided only a conclusory nexus statement without any reasoned medical explanation as to what data supported that conclusion and, importantly, why such data supported the opinion. Accordingly, the examination report is not adequate. On remand, the AOJ should obtain a new medical opinion that addresses whether the ophthalmic migraines and/or vasospasms underlying the Veteran's transient right eye vision loss are caused or aggravated by the left eye disability or its residuals. The opinion should support all conclusions reached with adequate rationale. The question of whether a higher level of compensation for service-connected left eye disability, pursuant to the provisions of the paired organ rule under 38 C.F.R. § 3.383, is intertwined with the outcome of the service connection claim and must therefore be remanded as well. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner addressing the etiology of the ophthalmic migraines and/or vasospasms that have been opined as the underlying cause of the Veteran's transient right eye vision loss. The examiner should review the entire claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. The examiner should then render an opinion as to whether it is at least as likely as not that the ophthalmic migraines and/or vasospasms are caused or aggravated by the Veteran's service-connected left eye disability or its residual effects. The examiner should note that opinions are required as to both causation AND aggravation. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. Complete rationale should include an explanation of the evidence used in support of the conclusion, as well as an explanation as to why such evidence supports the conclusion. 2. Once the above development has been achieved, as well as any other development deemed necessary thereafter, readjudicate the appeal. If any benefits sought remain denied, issue a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.