Citation Nr: 21063353 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 13-03 684 DATE: October 14, 2021 REMANDED Entitlement to service connection for a recurrent left eye disability, to include injury residuals, is remanded. REASONS FOR REMAND The Veteran had active service from June 1982 to September 1992. Entitlement to service connection for a recurrent left eye disability, to include injury residuals, is remanded. The service personnel records reflect that the Veteran's military occupation was dental specialist. The service treatment records show that she was seen for eye complaints due to foreign bodies including dental amalgam on several occasions including in April 1984, July 1984, September 1984, October 1984, November 1984, December 1984, February 1985, October 1985, January 1986, March 1986, March 1991, July 1991, and April 1992. In its June 2021 remand instructions, the Board of Veterans' Appeals (Board) directed that the Agency of Original Jurisdiction requested a Department of Veterans Affairs (VA) eye evaluation. The examiner was directed to opine "whether it is at least as likely as not (probability of 50 percent or more) that the current left eye disorders had their onset in service or are related to an in-service injury, event, or disease" and to "to specifically consider repeated instances of foreign bodies(including material from dental fillings) entering the Veteran's left eye during service, reports of in-service clouding and film sensation, contact lens use, and assessments of dry eye and conjunctivitis." A July 2021 eye evaluation conducted for VA conveys that the examiner reported that he was "unable to locate any evidence during service of documented treatment for instances of foreign bodies entering the left eye." He concluded that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner commented that: "as best as I can tell, there does not appear to be current or chronic ocular condition present consistent with in-service clouding and film sensation, contact lens use, and assessments of dry eye and conjunctivitis;" "these symptoms/conditions appear to have been acute or transient states which have resolved;" and "therefore, it is less likely than not that any current chronic or lasting left eye pathology is due to in service event consistent with Veteran reports." Given the examiner's failure to review the documented in service eye trauma, the Board finds that the July 2021 evaluation is of no probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Agency of Original Jurisdiction's compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, the Board concludes that further VA eye examination is needed. Clinical documentation dated after June 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any left eye disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after June 2021. 3. Schedule the Veteran for a VA eye examination conducted by the appropriate medical specialist to assist in determining the current nature of any identified recurrent left eye disability and its relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all left eye disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent left eye disability had its onset during active service or is related to any incident of service, including the documented in service eye trauma and complaints. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Smith, 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.