Citation Nr: 21062513 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 13-32 670 DATE: October 7, 2021 ORDER An initial compensable rating for bilateral eye stromal opacification is denied. FINDING OF FACT The Veteran's bilateral eye stromal opacification does not manifest as visual impairment or result in any incapacitating episodes. CONCLUSION OF LAW The criteria for a compensable initial rating for bilateral eye stromal opacification have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Codes 6099-6013. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1963 to March 1965. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for stromal opacification of the right and left eyes and assigned a noncompensable (0 percent) rating effective December 22, 2010. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in October 2016. A transcript of the hearing is associated with the claims file. In September 2017, the Board remanded this case for further development. Rating for bilateral eye stromal opacification As noted above, the Veteran was originally granted service connection for stromal opacifications of the right and left eyes in the April 2011 rating decision on appeal. At that time, he was assigned a noncompensable (0 percent) rating effective December 22, 2010. He is appealing that initial rating. The Veteran's bilateral eye stromal opacification is currently rated under hyphenated diagnostic code 6099-6013. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number is "built up" with the first two digits being selected from that part of the schedule most closely identifying the part, and the last two digits being "99" for an unlisted condition. Id. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15,316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, DC 6013 instructed the rater to evaluate open-angle glaucoma based on visual impairment with a minimum 10 percent rating if continuous medication is required. Revised DC 6013 instructs the rater to evaluate open-angle glaucoma under the General Rating Formula for Diseases of the Eye with a minimum 10 percent rating if continuous medication is required. Under the revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The criteria for visual impairment, including impairments of visual acuity, visual fields, and/or muscle function, have remained unchanged. Impaired visual acuity is rated under diagnostic codes 6061-6066 based on the best corrected distance vision. 38 C.F.R. §§ 4.76, 4.79. Impairment of visual fields are rated under DC 6080-6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Impaired muscle function is rated under DC 6090-6091 with an evaluation for diplopia being assigned to only one eye. 38 C.F.R. §§ 4.78, 4.79. When it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). The February 2011 VA eye exam recorded symptoms of bilateral eye redness, watering, glare, blurriness, impaired night vision, and photophobia. The Veteran also had distorted (irregular) image in his left eye. He did not have a history of hospitalization, surgery, trauma, eye neoplasm, or incapacitating episodes due to eye disease. Physical examination found no diplopia. His right eye macula had diffuse, small, hard drusen with pigment mottling, but no hemorrhages. His left eye macula had diffuse pigment mottling with large druse, but no hemorrhages. There was a visual field defect in that he had a left eye scotoma that was centrally located and measured three degrees. He did not have a corneal disorder that resulted in severe irregular astigmatism that could be improved more by contact lenses than by eyeglass lenses. His uncorrected distance visual acuity was 20/50 in the right eye and 20/250 in the left eye, both correctable to 20/25. His uncorrected near visual acuity was 20/250 in the right eye and 20/400 in the left eye, corrected to 20/50 in the right and 20/200 in the left. He had irregular lid margins bilaterally. +1-2 injection and +2 edema in the bilateral sclerae/conjunctivae, mid stromal haze in the bilateral corneas, flat/brown irises, and nuclear sclerotic cataracts bilaterally. He had bilateral presbyopia. There were no physical findings of abnormal lacrimal duct function, abnormal eyelids, chronic conjunctivitis, residuals of eye injury, lagophthalmos, symblepharon, ptosis, nystagmus, eyelash loss, or eyebrow loss. The Veteran had moderate stromal opacification which would cause a mild reduction of visual acuities and the halo/glare he described. The examiner estimated that the in-service eye injury described (a diluted ammonia mixture splashed into his eyes) would reduce the Veteran's vision from 20/20 to 20/20-2 with the amount of stromal haze present at the time of the examination. This condition would remain stable and not progress further. Additionally, this examiner found that the majority of the Veteran's current blurred vision was due to non-exudative age-related macular degeneration in the right eye and neovascular age-related macular degeneration in the left eye. His left eye was treated with eye injections. This macular degeneration was unrelated to his reported exposure to ammonia splashed into his eyes during service. The June 2021 eye conditions disability benefits questionnaire (DBQ) diagnosed bilateral exudative macular degeneration, pseudophakia, and corneal guttata. His uncorrected distance visual acuity was 20/100 in the right eye and 20/200 in the left eye, correctable to 20/40 in the right eye and 20/100 in the left eye. His uncorrected near visual acuity was 20/1000 in the right eye and 15/200 in the left eye, corrected to 20/40 in the right and 20/100 in the left. His pupils were round and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness in either eye. He did not have a corneal disorder that resulted in severe irregular astigmatism. He did not have diplopia. An external eye examination noted bilateral posterior chamber intraocular lenses, trace guttata, no edema or scarring of the cornea, and stroma clear bilaterally. Internally, there was scarring and diffuse retinal pigment epithelium atrophy in the bilateral maculae and remnants of recent anti-vascular endothelial growth factor injection present in the left vitreous. This examiner noted that the Veteran did not have a visual field defect. Nevertheless, testing was performed. The accompanying visual field perimeter chart showed visual fields as described below: (Continued on Next Page) Meridian Normal Right Eye Left Eye Temporally 85 75 75 Down temporally 85 70 70 Down 65 60 55 Down nasally 50 44 40 Nasally 60 60 55 Up nasally 55 53 55 Up 45 40 40 Up temporally 55 55 55 Total: 500 457 445 Average Concentric Contraction 62.5 57.125 55.625 This examiner found that the Veteran's bilateral trace guttata of the cornea without edema or other opacification did not result in any decrease in any visual acuity. Likewise, his bilateral postoperative cataracts with pseudophakia, but not aphakia or dislocation of the crystalline lens, did not result in visual impairment. The Veteran had clear posterior chamber intraocular lenses bilaterally with no abnormality that would lead to vision loss. Instead, his visual impairment was attributed to his retinal dystrophy. Specifically, this examiner found that the subfoveal location of retinal pigment epithelium atrophy and macular scarring is consistent with reduced visual acuity. He was currently receiving injections for this and had a history of injections in the bilateral eyes. The Veteran did not have scarring or disfigurement attributable to any eye condition. In the prior twelve-month period, he had more than seven documented medical visits to treat his neovascular age-related macular degeneration with injections. His eye conditions impacted his ability to work in that his photophobia required him to wear dark sunglasses and had previously lost a job when he requested reassignment because he could not pour concrete in a sunny area due to intense light reflections for the work surface. His neovascular age-related macular degeneration, which was not attributable to his military service, impeded his ability to function and feel comfortable driving out of town or long distances. This examiner noted that no evidence of stromal opacification was present on examination. There was an absence of any corneal opacification in either eye. The Veteran described a long history of light sensitivity with glare and halos following his in-service corneal burn injury. This improved dramatically after cataract surgery, which suggested that much of his symptoms were attributable to age-related cataracts rather than corneal scarring. Despite the mid-stromal haze described in the February 2011 exam, this examiner found no evidence of stromal haze present at the time of the examination and none of the other eye examinations reviewed suggested any evidence of corneal scarring. This examiner did find minimal corneal guttata as the only corneal abnormality present. This appeared to be an incidental finding, which was not visually significant, and was frequently found following cataract surgery, which may cause loss of corneal endothelial cells. VA treatment records throughout the period on appeal show a history of in-service eye injury and ongoing treatment for macular degeneration, bilateral cataracts, and refractive error. Throughout this period, the Veteran's visual fields were consistently full to finger count bilaterally. His extraocular movements were full and comitant. There was no showing of diplopia. He continued to have decreased visual acuity despite corrective lenses. The Veteran received eye injections for retinal problems due to age-related macular degeneration. He underwent cataract surgery in February 2018 for the left eye and in April 2018 for the right eye. Based in the above, the Veteran's bilateral eye stromal opacification does not manifest as visual impairment or result in any incapacitating episodes. No impairment of muscle function was shown. To the extent that decreased visual acuity and frequent incapacitating episodes are shown, these have been attributed to his separate, nonservice-connected age-related macular degeneration. While there is some inconsistency between the June 2021 DBQ examiner's finding that there was no visual field defect and the visual field measurements that show slight loss of visual field, this is not attributable to the Veteran's bilateral eye disability as there was no evidence of stromal opacification at the time of that examination. The Veteran reported light sensitivity with glare and halos at his February 2011 VA eye exam, which dramatically improved following his cataract surgery, strongly suggesting a link between these symptoms and his nonservice-connected cataracts. Moreover, the February 2011 eye exam that notes these symptoms does not attribute any additional functional impairment to them, instead noting that the majority of the Veteran's visual impairment and blurred vision was due to his nonservice-connected macular degeneration. As such, a compensable rating for bilateral eye stromal opacification is not warranted. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.