Citation Nr: 21063385 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-04 754 DATE: October 14, 2021 ORDER Service connection for a left eye disorder, including as secondary to the service-connected degenerative arthritis in the lumbar spine (lumbar spine disability), is denied. FINDINGS OF FACT 1. The Veteran has a current left eye disorder diagnosed as pterygium, presence of intraocular IOL, retinal tear with prior surgery, a visual field defect, and primary iridocyclitis. 2. The Veteran did not experience an in-service injury, disease, or event associated with the left eye. 3. The left eye disorder did not have its onset in service and is not otherwise etiologically related to service. 4. The left eye disorder was not caused by or worsened in severity by the service-connected lumbar spine disability. CONCLUSION OF LAW The criteria for service connection for a left eye disorder, including as secondary to the service-connected lumbar spine disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107, 7104; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from January 9, 1989 to April 10, 1989, November 27, 1990 to May 28, 1991, and from May 14, 1996 to July 15, 1996.The Veteran also had various periods of active and inactive duty for training purposes as a member of the Air Force Reserves from August 1988 to November 2009. This matter is on appeal from an August 2017 rating decision issued by the Regional Office (RO). The Veteran testified in Muskogee, Oklahoma, at a Board videoconference hearing in January 2020 before the undersigned Veterans Law Judge. The hearing transcript has been associated with the record. This matter was before the Board in May 2020. The Board remanded in order to obtain a VA examination and opinions addressing the Veteran's direct and secondary service connection theories. VA examinations and opinions were submitted to the record in April 2021. A supplemental statement of the case again denied the claim in April 2021. Duties to Notify and Assist The Board finds that the duties to notify and assist the Veteran in this case have been fulfilled. Neither the Veteran nor the representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Legal Authority for Service Connection Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Service connection for a left eye disorder, including as secondary to the service-connected lumbar spine disability, is denied. The Veteran proffers two theories of service connection. The Veteran contends that the current left eye disorder began in service and that he self-medicated with over-the-counter tear drops. See January 2020 Transcript. The Veteran also contends that the left eye disorder is related to the service-connected lumbar spine disability. Specifically, the Veteran claims that he as ankylosing spondylitis in the lumbar spine which causes or aggravates the current left eye disorder (primary iridocyclitis). See January 2020 Transcript. After a review of the evidence, the Board finds that Veteran has a current left eye disability diagnosed as pterygium, presence of intraocular IOL, retinal tear with prior surgery, a visual field defect, and primary iridocyclitis. The weight of the lay and medical evidence indicates that the Veteran did not experience an in-service injury, disease, or event associated with the left eye. Upon review of the service treatment records, there are no complaints of or treatment for a left eye disorder. While the Veteran now says that he self-medicated the symptoms in the left eye in service without visiting a military medical examiner, contemporary medical evidence that repeatedly indicates that the eyes were in normal condition weighs against that recent assertion. See January 1992 Military Medical Examination (The eyes were found to be in normal condition); January 2011 Report of Medical History (The Veteran affirmatively reported that he did not have eye trouble); December 1996 Military Medical Examination (The eyes were found to be in normal condition); April 1997 Report of Medical History (The Veteran affirmatively reported that he did not have eye trouble). The first time the Veteran reported the left eye disorder was in the instant claim in July 2017, several years after service separation. The Board is not relying on the absence of medical treatment evidence alone in the service treatment records as the basis for finding the contemporaneous evidence in the service treatment records is more probative than the Veteran's current assertion of having had an eye disorder during service, but is also relying on the Veteran's own lay reports of history during service, at which time he specifically denied any eye trouble during service. The Board finds that, while the Veteran is competent to render some medical statements because of his profession, his orthopedic medical training does not render him competent to diagnose ankylosing spondylitis or render a nexus opinion between a back disorder (especially ankylosing spondylitis that has not been diagnosed) and the anatomically remote eye disorder at issue. During the January 2020 Board hearing, the Veteran testified that after service separation he became a registered nurse, specializing in head injury and spinal cord injury. There is no suggestion, by the Veteran or the evidence, that any other back disorder than ankylosing spondylitis could have any effect on the eye disorder. Even with his medical training, the Veteran does not have a specialized knowledge of both the spinal column (specifically ankylosing spondylitis) and its effect on the eyes. As explained by the most recent VA examination opinion in April 2021, referenced below, the current left eye symptoms have multiple risk factors, some of which are non-service-related. As mentioned above, the Veteran's own contemporary lay statements in the service treatment records affirmatively deny left eye symptoms. See January 2011 Report of Medical History (The Veteran affirmatively reported that he did not have eye trouble); April 1997 Report of Medical History (The Veteran affirmatively reported that he did not have eye trouble). The service treatment records reflect complaints for minor medical symptoms like congestion, but there are no complaints of or treatment for left eye symptoms. See e.g., July 1996 Service Treatment Records (Complaints of congestion). The accurate fact of the Veteran's own denial of in-service left eye symptoms contemporaneous to service is one of the prongs the negative VA examination nexus opinion reasoning was based on. The weight of the lay and medical evidence also shows that the left eye disorder did not have its onset in service and is not otherwise etiologically related to service. In the April 2021 VA examination, the VA examiner rendered a negative medical nexus opinion based on direct service connection. The VA examiner reasoned that there are no records of treatment in service; that that redness of the eyes can be caused by a varying number of factors such as dryness, allergies, viral infection, bacterial infection, as well as inflammation; that if the Veteran had iridocyclitis (uveitis/iritis), it rarely goes away with the use of artificial tears; and in that in this case there are no signs of previous inflammation such as posterior synechiae from untreated iritis. The VA examiner suggested that the diagnosed pterygium in the left eye could have become inflamed and caused the redness in the eye. With regard to the secondary service connection theory (38 C.F.R. § 3.310), the evidence is against finding that the left eye disorder was caused by the service-connected lumbar spine disability. While the Veteran submitted August 2017 private treatment records indicating that ankylosing spondylitis in the lumbar spine can cause the left eye iridocyclitis, the private examiner noted that imaging is required to determine whether the Veteran has ankylosing spondylitis in the lumbar spine. See August 2019 Private Treatment Records ("Consider imaging of lower back to rule-out ankylosing spondylitis as [a] cause for iritis due to chronic back pain"). The private examiner's opinion was conditioned on whether the Veteran could be diagnosed with ankylosing spondylitis in the lumbar spine; the private examiner did not diagnose ankylosing spondylitis in the lumbar spine. In the April 2021 VA examination opinion, the VA examiner opined that the left eye disorder is less likely than not proximately due to or the result of the service-connected lumbar spine disability. The VA examiner reasoned that when evaluating uveitis typically medical professionals conduct a series of blood tests and/or x-rays to rule out systemic causes and they assess whether the patient has lower back pain. The term spondylitis is a descriptive term of degeneration of the spine such as degenerative disc disease or osteoarthritis. Ankylosing spondylitis is arthritis in which there is a long-term inflammation of the joints of the spine. Since in this Veteran's case the evidence shows no ankylosing spondylitis in the x-rays presented, dated in June 2016, September 2017, and August 2018, this was part of the rationale for the VA examiner's negative nexus opinion. The Board finds that the August 2017 private medical opinion is outweighed by the April 2021 VA examination opinion because the private opinion is a general statement of possible association and is speculative. The private opinion is based on the possibility of the Veteran having ankylosing spondylitis in the lumbar spine, when the evidence does not show a diagnosis of ankylosing spondylitis in the lumbar spine, especially after multiple testing that would have revealed it if it were present. Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (favorable evidence which does little more than suggest possibility of causation is insufficient to establish service connection); Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was "possibly" suffering from a disability was deemed speculative); Black v. Brown, 5 Vet. App. 177, 180 (1993) (an examination not based on the record, but based on inaccurate facts presented to an examiner, is speculation). In contrast, the April 2021 VA examination opinion is based on accurate factual assumptions that include no diagnosis of ankylosing spondylitis, comprehensive reasoning, and a thorough explanation in the rationale. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (upholding Board determination that VA examination reports were more probative because they were more thorough and detailed, they discussed the conflicting opinions, and examiners had access to the claims file); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (a thorough and contemporaneous medical examination is "one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one). The opinion is also based on the accurate factual assumption that ankylosing spondylitis is not shown in this case. Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim). The weight of the lay and medical evidence is against finding that the left eye disorder was worsened in severity by the service-connected lumbar spine disability. As the Veteran does not have ankylosing spondylitis, any assertion of secondary causation or aggravation by the ankylosis spondylitis is not even reached. Both the private medical examiner and the VA examiner agreed that, in order for there to even be a possibility of association between the ankylosing spondylitis and the eye disorder, there must be a confirmed diagnosis (by medical imaging) of the ankylosing spondylitis. In this case, the evidence shows no ankylosing spondylitis; therefore, there is nothing associated with the service-connected back disability (that does not include ankylosing spondylitis) that can act on the eye disorder, either by causation or by aggravation, or to even suggest such secondary association. In El-Amin v. Shinseki, the appellant filed for service connection for a veteran's cause of death (hepatic cirrhosis). The appellant argued that the service-connected posttraumatic stress disorder caused or aggravated the veteran's alcoholism which, in turn, led to the cirrhosis. A VA examiner generically said that the death of the veteran was due to other causes than the service-connected posttraumatic stress disorder, but the examiner did not rule out the possibility that the service-connected PTSD did not aggravate the alcoholism that led to the veteran's death, and the Board improperly assumed that the statement was sufficient for an aggravation opinion. 26 Vet. App. 136, 140 (2013) (holding a Board's VA examination adequacy finding clearly erroneous where the VA examiner's opinion focused solely on direct causation and did not address aggravation). In El-Amin, the Court recognized that there was some plausible basis to suggest a possibility of aggravation of the hepatic cirrhosis by the PTSD that could have caused the alcoholism, whereas in this case there is nothing about the back disability, which is anatomically remote and of a different body system, that raises a suggestion of secondary association, including by aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (holding that a medical opinion that focuses solely on causation is inadequate to address whether a service-connected disability aggravated another condition). Additionally, a VA examiner rendered a negative opinion in April 2021 VA examination on the question of aggravation and it was negative because the Veteran does not have the ankylosing spondylitis, which is the only type of back disorder that could possibly act on an eye disorder. Based on the foregoing, the Board finds that criteria for service connection for a left eye disorder, including as secondary to the service-connected lumbar spine disability, have not been met; as such, the claim must be denied. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Costantino, 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.