Citation Nr: 21064168 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-08 057 DATE: October 19, 2021 ORDER Entitlement to service connection for macular degeneration, right eye (right eye disability) is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's current right eye disability had its onset in active duty service or is otherwise related to service. CONCLUSION OF LAW The criteria for service connection for right eye disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1976 to December 1982. In July 2019 and April 2021, the Board remanded the claim for further development. A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110 (2012). To establish an entitlement to service connection for a disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). For VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. Analysis The Veteran contends that his right eye disability is due to military service. Specifically, he argues that his disability is the result of the 1978 blunt force head trauma. The Veteran has been diagnosed with right eye macular degeneration/geographic atrophy and high myopia with astigmatism. As such, element one under Shedden is met. The Veteran's service treatment records (STRs) document complaints and treatment for a head injury. As such, element two under Shedden is met. During his November 1975 Report of Medical Examination, Entrance exam, the Veteran's eyes, pupils, ophthalmoscopy test, and ocular mobility were clinically normal. The Veteran stated that he did not have eye trouble. In January 1977, the Veteran received two pairs of military glasses. On June 11, 1978, the Veteran was seen at the branch hospital for laceration to the occipital area of his head. The traumatic laceration was 3 cm on the right (illegible). On June 16, 1978, the Veteran was seen for a reevaluation of a head trauma. The Veteran had been seen on June 11 (illegible) area was still swollen. In May (illegible), the Veteran underwent an eye exam. (Illegible). During his October 1982 Report of Medical History, Discharge exam, the Veteran's pupils, ocular mobility and eyes were clinically normal. However, after examining the Veteran's vision, the examiner recommended further specialist examination of the Veteran's eyes. In April 2007, the Veteran saw his private optometrist for poor vision. The examiner diagnosed the Veteran with macular degeneration, OD (right eye). In his March 2012 statement, the Veteran stated that he had problems with a few Marines. One night, a blanket was thrown over his head and several men began to hit him. He was punch in the back of the head. He began to bleed and was taken to the hospital. He was eventually prescribed glasses, but his vision got worse and worse. In 2007, he was told that he had a node in his right eye. He was asked if he had ever been hit at the back of his head and was also told that any blunt hit could probably cause vision problems. In February 2013, the Veteran was afforded a VA examination to determine the nature and etiology of his right eye macular degeneration. The Veteran had had a progressive decrease in right eye vision and was eventually diagnosed with macular degeneration/geographic atrophy. The Veteran also had many years of significant myopia with astigmatism. The examiner confirmed the Veteran's right eye macular degeneration/geographic atrophy, nuclear sclerotic cataract, and high myopia with astigmatism diagnoses. The examiner opined that none of the Veteran's current ocular/visual problems were caused by or a result of the head injury he incurred on active duty service. On his February 2016 Substantive Appeal (VA Form 9), the Veteran stated that blunt force trauma can damage the cornea, retina, lens, and optic nerve resulting in a number of conditions to include, retina bleeding, swelling, detachment and blurred vision, and light sensitivity. Blunt force trauma applied with sufficient force to require stitches and leave a permanent scar would fit into this category. The symptoms may or may not be noticed if it is on only one eye because the good eye will compensate. The Veteran stated that when he joined the Guard, he had an eye exam, and he knew he was experiencing a feeling of diminished vision. In March 2017, the Veteran saw his private physician regarding his right eye disability. The examiner confirmed the Veteran's right eye age-macular degeneration and age-related cataract. In August 2017, the Veteran underwent cataract surgery. His after surgery diagnosis was right eye pseudophakia. In August 2020, the Veteran was afforded another VA examination to determine the nature and etiology of his right eye disability. The examiner was asked to opine and provide a rationale as to whether the Veteran has a diagnosis of macular degeneration that is at least as likely as not (50 percent or greater probability) incurred in or caused by the in-service head injury. The examiner confirmed the Veteran's bilateral macular degeneration and pseudophakia (the presence of an artificial lens found in patients who have had cataract surgery) diagnoses. The examiner opined 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 also opined that the claimed condition is less likely than not due to the Veteran's service-related injury. The examiner stated that if the injury to the occipital bone had resulted in vision loss, the vision loss would most likely have occurred in the right eye at the time of injury or shortly thereafter. The examiner stated that, on the day of the exam, the appearance of the Veteran's eyes did indeed reflect profound visual impairment; however, it looked like the regular progression of age-related macular degeneration (ARMD). The examiner stated that it was his impression that the head injury was largely independent of the current ocular disease and vision loss. The examiner further stated that it may be possible that the head injury did affect the Veteran's vision and it was worth noting that the Veteran was apparently 20/20 in both eyes without correction at his 1975 entrance exam and only had 20/70 vision in his right eye at the time of his 1982 discharge exam. However, the injury is not the only reasonable explanation (i.e. progressive myopia, cataract, etc.) for vision change between 1975 and 1982. The examiner stated at the time of the exam, it would be difficult to determine a reason why the Veteran was 20/70 at discharge because each macula is so scarred from ARMD (the injury would have had a much milder appearance that has now be dwarfed by the ARMD damage), and his natural lenses have been removed. The examiner was also asked to opine is it at least as likely as not (i.e. 50 percent probability or greater) that the Veteran's eye condition, to include macular degeneration, either began during or was otherwise caused by or related to military service. The examiner opined 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 stated that the current appearance and function of the Veteran's eyes is consistent with normal, end-stage macular degeneration. Both eyes show similar and devastating scarring to each macula. There has been no evidence presented that suggests military service was a cause for his eventual vision loss. He apparently sustained some vision loss from the occipital injury as noted at his discharge examination. However, this finding is not necessarily due to the eye problem he is currently affected by; namely, macular degeneration. Many conditions including refractive error may have led to his 20/70 vision at discharge. If an ocular problem occurred due to the injury there is no way to reconstruct the progression of pathology, i.e., there is no macula left to infer clues to other milder forms of vision loss. The examiner stated that barring additional evidence, he found it highly unlikely that the injury was a cause for the Veteran's macular degeneration and subsequent legal blindness. Based on the evidence of record, the Board finds that service connection for the Veteran's right eye disability is not warranted. The Veteran's STRs document complaints and treatments for a laceration to the occipital area of his head. Additionally, the Veteran was provided with two pairs of glasses in service. However, the 2020 VA examiner opined that the claimed condition, to include macular degeneration, was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that if the injury to the occipital bone had resulted in vision loss, the vision loss would most likely have occurred in the right eye at the time of injury or shortly thereafter. The examiner stated that the current appearance and function of the Veteran's eyes is consistent with normal, end-stage macular degeneration. On the day of the exam, both eyes showed similar and devastating scarring to each macula. It was the examiner's impression that the head injury was largely independent of the Veteran's current ocular disease and vision loss. The examiner further stated that it may be possible that the head injury did affect the Veteran's vision, and it was worth noting that the Veteran was apparently 20/20 in both eyes without correction at his 1975 entrance exam and only had 20/70 vision in his right eye at the time of his 1982 discharge exam. However, the injury is not the only reasonable explanation for vision change between 1975 and 1982. The examiner stated at the time of the exam, it would be difficult to determine a reason why the Veteran was 20/70 at discharge because each macula was so scarred from ARMD (the injury would have had a much milder appearance that has now be dwarfed by the ARMD damage), and his natural lenses had been removed. The examiner stated that barring additional evidence, he found it highly unlikely that the injury was a cause for the Veteran's macular degeneration and subsequent legal blindness. Additionally, the Veteran's March 2017 private physician described the Veteran's macular degeneration as age related. The Board also notes that the first medical evidence of right eye macular degeneration was in 2007, i.e., 25 years after discharge from service. The fact that there were no records of any complaints or treatments involving the Veteran's right eye disability for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints). The Veteran's VA treatment records also show diagnoses of myopia with astigmatism and age-related cataract, to include cataract removal of and the resulting pseudophakia. The Board notes that refractive errors of the eyes, which includes myopia and astigmatism, are not diseases or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9. Accordingly, as to myopia, service connection is not warranted. As to the Veteran's cataracts and the resulting pseudophakia, there is no evidence that the Veteran had such diagnoses during active service. Additionally, the Veteran's March 2017 private physician described the condition as age related. After considering all the evidence under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to service connection for cataract and pseudophakia. Additionally, the first medical evidence of cataracts and the resulting pseudophakia was in 2013 and 2017, respectively, i.e., 31 and 35 years after discharge from service. The fact that there were no records of any complaints or treatments involving the Veteran's cataracts and the resulting pseudophakia for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints). Therefore, the Board finds that element three under Shedden has not been met. The Board has considered the Veteran and his representative's statements regarding the etiology of the Veteran's right eye disability. The Board notes that although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, a nexus between the right eye disability and active service is outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n. 4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In the absence of a nexus, the claim for service connection for right eye disability is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore 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.