Citation Nr: 21065988 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 19-35 761 DATE: October 28, 2021 ISSUES 1. Entitlement to service connection for a hernia disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a loss of vision disability, status post surgery in service. 4. Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected disability. 5. Entitlement to service connection for a vertigo disability, claimed as secondary to service-connected disability. ORDER Entitlement to service connection for a hernia disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a loss of vision disability, status post surgery in service is denied. Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected disability is denied. Entitlement to service connection for a vertigo disability, claimed as secondary to service-connected disability is denied. FINDINGS OF FACT 1. A hernia disability was not manifest in service and is not otherwise attributable to service. 2. A left knee disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 3. A loss of vision disability, status post surgery in service, was not manifest in service or within one year of separation, and is not otherwise attributable to service. 4. Coronary artery disease was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 5. A vertigo disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. A hernia disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. A left knee disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. A loss of vision disability, status post surgery in service, was not incurred in or aggravated by service, and organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. Coronary artery disease was not incurred in or aggravated by service, arteriosclerosis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. A vertigo disability was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1953 to January 1956. This matter is before the Board of Veterans Appeals (Board) on appeal from a June 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in February 2021. A copy of the hearing transcript has been associated with the claims file. Next, the Board observes that these issues and others remanded by the Board in March 2021. Later, an August 2021 rating decision granted several claims. The issues reflected on the title page remained on appeal. The Veteran is currently in receipt of a 100 percent, total combined disability rating from February 25, 2017, including special monthly compensation (SMC) under both 38 U.S.C. §§ 1114 (k) and 1114 (s). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran and his representative previously raised two threshold issues related to the duty to assist. They are missing Service Treatment Records (STRs) destroyed in a fire, and the resulting heightened duty to assist in developing his claims. First, in addressing the STRs, only the blurry Report of Medical Examination is of record. The typed dates are illegible, and it is not certain if this is from separation. Still, it shows no diagnosed disabilities. Later, in April 2017, a determination was made that the outstanding records are "fire-related." As the RO recapped in the June 2017 rating decision: The National Personnel Records Center (NPRC), St. Louis Missouri, in response to VA requests, reported the records may have been destroyed in a fire at the Records Center in 1973. NPRC could not confirm the existence of such records; only the fact that if they had been stored at the Records Center, they would have been stored in an area damaged by the fire. If these records are located at a later date, this decision will be reconsidered. If a different decision results, that decision will be effective as of the date of this pending claim. The Board observes that where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule where applicable. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). In this matter, the Board's development and analysis of the Veteran's claims has been undertaken with this heightened duty. We have also considered this duty in reaching the decisions below. Second, throughout the appeals period, the Veteran through his representative previously raised duty to assist errors. He has presented lay evidence of disability since the inception of the claims, which we discuss under each issue below. The January 2018 Notice of Disagreement (NOD) generally cited a duty to assist error in not fully developing the Veteran's claims. The November 2019 VA Form 9 contains two main arguments. VA failed to consider the evidence, facts, and statements; and VA failed by not fully developing the claims. At the February 2021 Hearing, the Veteran's representative argued, "Now this man has endured so much, and I feel that having given credible lay person testimony as opposed to any evidence to the contrary from VA, he's giving credible testimony here today... So at the very least, Your Honor, VA should have at least afforded him a Compensation & Pension examination. They did not." See February 2021 Hearing Transcript, p. 26. The Board observes that the Veteran has variously described "examinations" as part of his clinical treatment through VA, including in October 2020. See, e.g., February 2021 Hearing Transcript, p. 19. He has since been afforded a battery of VA compensation and pension (C&P) examinations. Updated VA treatment records since May 2017 were also obtained and associated with the claims file. Recently, the Veteran was notified of the critical evidentiary requirements necessary to substantiate his claims by way of the August 2021 Supplemental Statement of the Case (SSOC). He raised no specific objections. The Veteran in this case has not referred to any additional deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2) 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). We note that arthritis, arteriosclerosis, and organic disease of the nervous system are chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as "chronic." See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for a hernia disability 2. Entitlement to service connection for a left knee disability The Board incorporates its discussion from the sections above by reference. By way of background, the sole Service Treatment Record (STR) of record is a blurry Report of Medical Examination. The typed dates and purpose of examination are illegible. Still, it disclosed all clinically normal evaluations. Next, the January 2018 VA 21-4138 Statement in Support of Claim reads in part, "While in basic training, I recall falling with full gear and injuring my left knee. I did report to Sick Call. That injury bothers me still." Later, at the hearing, the Veteran testified, "I don't remember (inaudible) with anybody or talking about the injury. (inaudible). We were out in the woods away from the barracks and everything else." He testified that he did not remember talking to a medic. See February 2021 Hearing Transcript, p. 6. He has felt uncomfortable and off balance in his left leg after that incident. Id. at p. 7. Turning to the hernia, the Veteran testified that he had the beginning of a hernia in service, but it was "small-scale." See February 2021 Hearing Transcript, p. 8. He later sought treatment: The only thing that I found out was that I needed an operation after I got out of the service. (inaudible) told me there was a small opening on the (inaudible). And (inaudible) is so small to have (inaudible). But anyway, I had the hernia operated, and now I have a big lump on the left-side, that the operation was on the right side on the lower part. And this one is from the lower part on the left side. See February 2021 Hearing Transcript, p. 8. Next, the issues were remanded by the Board in March 2021. Pursuant to O'Hare and in light of the Veteran's contentions, the Veteran was afforded a series of VA examinations to determine the nature and etiology of any left knee disability and hernia disability. First, the Veteran was afforded an August 2021 VA knee and lower leg examination with Disability Benefits Questionnaire (DBQ). The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner documented the Veteran's account that the condition began while running and walking in service. He was not treated at that time. Symptoms were pain in the left knee and control of the knee when it gives out. He had no current treatment plan. The VA examiner identified left knee strain. Next, the VA examiner rendered a negative nexus opinion for the left knee, implicitly encompassing all theories of direct and presumptive service connection. The VA examiner reasoned: The left knee disability is less likely than not (Less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. The veteran stated that his left knee condition while walking on soft mud and then walking on the hard ground, his left knee went out. I could not find any medical records from the service treatment records or separation exam that document any injury to his left knee. There is no supporting evidence that the veteran's condition was incurred while in the Military. Turning to a hernia disability, the August 2021 VA examiner also performed a complete examination, documented in a VA hernia DBQ. As part of reviewing the entire claims file, the VA examiner highlighted a treatment record dated September 12, 2019 showing inguinal hernia. The VA examiner documented that the Veteran reported his hernia began in 1954 while carrying heavy equipment and machinery. His symptoms were dull pain and bulging in the perineal area of left groin. He was treated with a hernia repair, but it then reoccurred. He was planning to have his hernia repaired, and could not lift anything or participate in strenuous activities. Next, the VA examiner rendered a negative nexus opinion for the hernia disability, implicitly encompassing all theories of direct and presumptive service connection. The VA examiner reasoned: The veteran's hernia condition is less likely as not (Less than 50 percent or less probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. There are no STRs that document a hernia in the Veteran's VA records while in the Military. There is a note dated 9/12/2019 that documents the need for cardiac clearance for a hernia operation. During the veteran's evaluation today he presented with a very large left inguinal hernia. It was reducible and the veteran stated he reduced it every night when he went to bed. The veteran stated he had a hernia in the military and had surgery to repair it while in the military. I found no scar to indicate a previous hernia surgery. There is no evidence to support the claim of a hernia while in the military. Additional VA treatment records are substantially the same. The issue remains a nexus between currently diagnosed disability and events in service several decades ago. The Veteran contends that he is entitled to service connection for a hernia disability and a left knee disability. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report pain in the left knee and in the perineal area or left groin. The Veteran is also competent to relate what he has been told by a professional. He is competent to report when he was diagnosed with a left knee strain and hernia. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of any left knee or hernia disability are not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records and the medical opinions of the August 2021 VA examiner. First, we have considered our heightened duty under O'Hare. The Board has provided the Veteran with a hearing and subsequent VA examinations that included consideration of his lay statements. Several decades after separation, the Veteran filed his service connection claims. As highlighted by the VA examiner, treatment records show a notation of a hernia in 2019. Regarding the left knee, the Veteran reported to the examiner that he was not treated in service and still had no treatment plan for his knee, despite lay reports of impairment due to pain and the knee giving out. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the comprehensive medical opinions of the August 2021 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. The VA examiner rendered negative nexus opinions for all theories of direct and presumptive service connection for the hernia and left knee, which considered all neurological manifestations. The negative nexus opinions are supported by the objective evidence in the claims file, as cited to by the VA examiner. The VA examiner thoroughly considered the Veteran's own lay history in light of the missing STRs, which she acknowledged. Nevertheless, the Veteran's lay accounts of events from over half of one century earlier are outweighed by the clinical findings of the VA examiner. In reaching the conclusions, the VA examiner applied her medical expertise. For example, for the hernia, the VA examiner reasoned in part, "The veteran stated he had a hernia in the military and had surgery to repair it while in the military. I found no scar to indicate a previous hernia surgery." He also denied any history of treatment in service or since then for a left knee disability. The negative nexus opinions are supported by additional reasons and bases citing to evidence in the claims file. Therefore, we assign the most probative weight to the negative nexus opinions of the August 2021 VA examiner. Regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Hernia and left knee disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being told that he has a remote diagnosis of a left knee strain and hernia, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of chronic conditions many decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and August 2021 medical opinion does not demonstrate such continuity. The VA examiner described the Veteran's medical history showing the remote onset of the claimed disease entities several decades after separation. Any recollections of groin or knee pain in service were acute, transitory, and resolved by separation, with no chronic residuals. Consequently, we find that service connection on a direct and presumptive basis for hernia and left knee disabilities is not warranted. We have also considered the Veteran's lay statements to the extent that he is competent to relate current pain in the left knee and groin area. The Board is mindful that this is important in light of the missing STRs. However, such remote statements they are outweighed by the medical evidence of record. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Recently, in Wait v. Wilkie, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause "functional impairment of earning capacity," and therefore meet the current disability requirement under Saunders. Wait v. Wilkie, 33 Vet. App. 8, 2020 U.S. App. Vet. Claims LEXIS 1609, 2020 WL 5200689. The CAVC held that, to meet the current disability requirement under Saunders, "there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." The CAVC clarified that the Board must make the factual determination whether the appellant's manifestations rise to the level of a functional impairment in earning capacity. For these issues, the Board has assigned the most probative weight to the contemporaneous medical records and the findings of the August 2021 VA examiner. The VA examiner reviewed the lay history and ongoing VA treatment records. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. The weight of the evidence establishes the remote onset of any left knee and hernia impairment. There is also no other positive nexus opinion submitted by the Veteran or his representative that contrasts with the clinical findings of the VA examiner. Additionally, we considered Saunders for all theories of entitlement. Once again, any alleged pain in service was acute only, and is unrelated to chronic disability identified several decades later. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for hernia and left knee disabilities is not warranted. 3. Entitlement to service connection for a loss of vision disability, status post surgery in service The Board incorporates its discussion from the sections above by reference. As a threshold matter, the Board observes that absent an eye injury resulting in disability, refractive error is not a service-connectable disability entity for VA purposes. Refractive errors of the eyes are congenital or developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303 (c), 4.9; McNeely v. Principi, 3 Vet. App. 357, 364 (1992). In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Id. Indeed, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990) (cited at 55 Fed. Reg. 45,711) (Oct. 30, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Distinctly, the Veteran contends that he has impairment of his vision stemming from a right eye injury in service that required surgery. By way of medical history, the Veteran described an injury in the January 2018 VA 21-4138 Statement in Support of Claim. He recounted: While stationed in Etain Meuse Lorraine, France, I began having problems with my vision. I developed an eye problem. My vision was blurry. When I joined the Army my vision was 20/20. My NCO Sergeant noticed I had a physical growth in my eye and arranged for me to seek medical attention. I was transported to Landstuhl, Germany, for an examination and had surgery on my eye. The surgery did not help much in that now I have a permanent spot in my right eye that impairs my vision. Later, the Veteran provided consistent hearing testimony: Yeah, I had surgery in Germany, (inaudible), Germany for an operation on the right eye. The local sergeant, doctor at the clinic saw me and he recommended that I get, to see the eye doctor, and he think that I should go to (inaudible), Germany because I was stationed in France. And I don't think that they had services there, but they had an American hospital in (inaudible). Again, I was taken there, operated on, operation on the right eye, and I still see a spot on that operation. And that was done, I don't remember, maybe 1955 or late '54 while I was stationed in France and (inaudible), Germany for the operation. See February 2021 Hearing Transcript, p. 10. The Veteran clarified that a "spot" on his right eye is what impairs his vision. Pursuant to O'Hare and in light of the Veteran's contentions, the Veteran was afforded a VA examination to determine the nature and etiology of any right eye vision disability. Next, the Veteran was afforded a July 2021 VA eye conditions examination with DBQ. The VA optometrist elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner identified several remote eye disabilities. The VA examiner also documented a lay history. The Veteran was "not sure" why he was there that day. He had blurred vision many years ago. He had eye surgery in service for Pterygium, and recently had cataract surgery for the left eye about 1-1/2 years ago. His current symptoms were dry eyes, droopy eye lids, and blurred vision. Next, the VA optometrist went on to render a negative nexus opinion, implicitly encompassing all theories of direct and presumptive service connection. The VA examiner reasoned: There are multiple eye conditions superimposed that contribute to vision loss. The major contributors to vision loss are Macular degeneration ou, Cataract od., Dry Eye Syndrome ou, Ptosis with superior VF loss and are consistent with Veterans age of 87 y/o. Veteran reports that he had Pterygium surgery right eye however there are no MR or STR presented to represent that surgery. The residual Pterygium is well healed, stable, and unlikely to cause significant vision loss other than transient irritation and tearing. Additional VA treatment records are substantially the same. The issue remains a nexus between eye disability for VA purposes and events in service. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report blurred vision and dry eyes. The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for loss of vision, and when Pterygium surgery was first performed by professionals. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence are the contemporaneous treatment records and the opinion of the July 2021 VA examiner. First, although there are not complete STRs, the Veteran has offered a lay history of surgery in service. Years later, including at the VA examination, a set of remote eye disabilities were identified. The Board assigns significant probative weight to the contemporaneous treatment records. Second, the Board assigns the most probative weight to the detailed negative nexus opinion of the July 2021 VA examining optometrist. The VA examiner reviewed the entire claims file, and provide detailed reasons and bases. The VA examiner sympathetically considered and discussed the Veteran's lay history. The VA examiner ultimately opined that the superimposed eye conditions that lead to vision loss are less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The VA examiner applied his medical expertise as an optometrist in addressing the Veteran's history of eye surgery. He explained in part, "Veteran reports that he had Pterygium surgery right eye however there are no MR or STR presented to represent that surgery. The residual Pterygium is well healed, stable, and unlikely to cause significant vision loss other than transient irritation and tearing." The negative nexus opinion was reached using medical expertise and citing to evidence in the claims file. We find this to be the most probative evidence of record. Regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. It was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report blurry vision, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as organic disease of the nervous system, pales in probative weight when compared to the objective medical evidence of record. The lay hearing testimony of events from years earlier has been considered. However, the Board has assigned more probative weight to the contemporaneous medical records and the findings of the July 2021 VA examiner. The VA optometrist reviewed the treatment records and considered the Veteran's lay history. The VA examiner provided detailed reasons and bases, citing other "major contributors" to current blurred vision. We have found the negative nexus opinions to be the most probative evidence of record. Consequently, we find that service connection on a direct and presumptive basis for an eye dsiability is not warranted. In short, the most probative evidence is the contemporaneous treatment records and July 2021 VA negative nexus medical opinions. A loss of vision disability, status post surgery in service, was not noted or manifest during service. In addition, the Veteran's own lay opinion pales in probative weight (regarding identifying a potential chronic disease entity in service) when compared to the objective medical evidence of record. The evidence establishes a remote onset of any eye disability when compared with the most probative evidence of record. Moreover, refractive errors of the eyes alone are congenital or developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303 (c), 4.9; McNeely v. Principi, 3 Vet. App. 357, 364 (1992). We also considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). However, there is no other superimposed eye disability related to disease, injury, or other events in service, including eye surgery. Even assuming additional eye pathology were identified, though we do not concede this, there is still no link to service (nexus). Therefore, service connection for a loss of vision disability, status post surgery in service, is not warranted. 4. Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected disability 5. Entitlement to service connection for a vertigo disability, claimed as secondary to service-connected disability The Board incorporates its discussion from the sections above by reference. As a threshold matter, the Veteran's representative asserted at the end of the February 2021 Hearing that these two conditions are claimed as secondary to other disabilities currently on appeal. As such, any future medical opinion needed to encompass a theory of secondary service connection. See February 2021 Hearing Transcript, p. 25. Turning to the lay evidence, the Veteran testified that he experiences dizzy spells and issues with balance. He had an appointment with a cardiologist and was told that this was an issue with his ears rather than his heart. He saw an ear doctor in October, likely meaning in October 2020. See February 2021 Hearing Transcript, p. 19. Still, he has never been provided with a formal diagnosis by a treatment provider. Next, in March 2021, the Board determined that the Veteran should be afforded a VA examination to determine the nature and etiology of any coronary artery disease and vertigo. On remand, the Veteran was invited to submit any private medical opinions. Later that year, the Veteran was afforded an August 2021 VA heart conditions examination with DBQ. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. In relevant part, the VA examiner identified acute, subacute, or old myocardial infarction from September 9, 2013, and coronary artery disease (CAD) from September 9, 2013 and September 12, 2019. Next, the VA examiner rendered a set of negative nexus opinions encompassing all theories of direct, presumptive, and secondary service connection. For direct and presumptive service connection, the VA examiner reasoned: The veteran's heart condition is less likely as not (Less than 50 percent or less probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. There is no evidence or STRs that document a heart condition in the veteran's VA e folder. The veteran stated that his heart condition started when he had chest pressure and was taken to the hospital and placed a stent in it Patient reports admission Sep 9, 2013 to Sep 13, 2013 at Harlingen Medical Center with care by Dr. [F.]. State in patient's own words the reason for recent admission to the hospital. States he started having chest pain at home and went to ER. The veteran stated that he did not have an MI but almost did. He had a PTCA with a stent placement. On page 644 dated 10/29/12 a diagnosis of Hypercholesterolemia. There is no evidence to support the claim that the heart condition was incurred while he was in the military. The veteran left the military in 1956, nearly 64 years ago. Turning to secondary service connection, the VA examiner similarly rendered a negative nexus opinion for all theories of entitlement, including proximate cause and aggravation. Also in August 2021, the Veteran was afforded a VA ear conditions examination. The VA examiner documented a lay history from the Veteran that his vertigo problems began in 1953 while marching with the army. He feels off balance when he walks. He has not received treatment. The VA examiner ultimately identified peripheral vestibular disorder and hearing loss with tinnitus, both with a date of diagnosis in May 2021 corresponding to an audiogram with hearing loss and tinnitus. Next, the VA examiner rendered a set of negative nexus opinions encompassing all theories of direct, presumptive, and secondary service connection. For direct and presumptive service connection, the VA examiner reasoned, "The veteran stated that he did not have vertigo. He feels off balance with his left knee. He also stated that he felt his ears were plugged up and did not feel he had vertigo once I described it to him." Regarding secondary service connection, the VA examiner similarly rendered a negative nexus opinion for all theories of entitlement, including proximate cause and aggravation. Additional VA treatment records are substantially the same. The Veteran contends that he is entitled to service connection for CAD and a vertigo disability, both claimed as secondary to service-connected disability. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report feeling off balance when ambulating. The Veteran is also competent to relate what he has been told by a professional. He is competent to report that he was diagnosed with coronary artery disease in 2013. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of any arteriosclerosis or ear disability are not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records and the negative nexus opinions of the August 2021 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. The VA examiner rendered negative nexus opinions for all theories of entitlement for the coronary arteries and ears, which considered all neurological manifestations. The negative nexus opinions are supported by the medical evidence in the claims file, as cited to by the VA examiner. Decades after separation, the Veteran was diagnosed with CAD and suffered a myocardial infarction. The VA examiner reasoned, "The veteran stated that his heart condition started when he had chest pressure and was taken to the hospital and placed a stent in it Patient reports admission Sep 9, 2013 to Sep 13, 2013 at Harlingen Medical Center with care by Dr. [F.]." He also described impairment ambulating, which he related to his left knee condition when informed of the specific medical definition and symptoms of vertigo. He reported suffering falls. Those have been attributed by his lay statements and in the knee examination above to his left knee giving out. In reaching these findings, we are mindful heightened duty under O'Hare. Accordingly, as part of the rationale for the negative nexus opinions, the VA examiner documented, "The veteran stated that he did not have vertigo. He feels off balance with his left knee." Therefore, we assign substantial probative weight to the negative nexus opinions of the August 2021 VA examiner. Regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. CAD and vertigo disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being told by his physician that he has a diagnosis of CAD, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as arteriosclerosis or organic disease of the nervous system, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first service connection claims several decades after separation. Consistently, the Veteran's lay history documented in the VA examination places the onset of heart disability decades after discharge to 2013, as corroborated by the medical evidence. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that "evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and August 2021 VA medical opinions does not demonstrate such continuity. The VA examiner described the Veteran's medical history showing the remote onset of the claimed disease entities several decades after separation. Therefore, we find that service connection on a direct and presumptive basis for CAD and vertigo disabilities is not warranted. Next, it appears the Veteran's theory of entitlement to service connection for CAD or vertigo is also one of secondary service connection. More specifically, he contends that these disabilities are secondary to his service-connected disabilities and functional impairment. 38 C.F.R. § 3.310. The VA examiner highlighted that the Veteran's own lay history suggested other, non-service connected factors causing his falls, unrelated to vertigo. In particular, the Veteran is not service-connected for a left knee disability. There is also no positive nexus for CAD based upon the VA examiner's medical expertise, including for all theories of secondary service connection. The VA examiner utilized ultimately rendered a negative nexus opinion. We note other, non-service connected factors. In conclusion, the Board has sympathetically considered the evidence of record, and finds that CAD and vertigo disabilities are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. There is also no other competent and probative evidence establishing that any claimed disability is due to any service connected disease or injury. We specifically considered the Veteran's lay statements to the extent that he is competent to relate current feelings of imbalance. However, they are outweighed by the medical evidence of record. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the Veteran's lay history (to the extent it is competent) and the findings of the August 2021 VA examiner. The VA examiner reviewed the VA treatment records, objective test results, and considered the Veteran's lay hearing testimony. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. The most probative evidence establishes the remote onset of any CAD or balance impairment. There is also no nexus to any service-connected disability. 38 C.F.R. § 3.310. We note other factors. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for CAD and vertigo disabilities is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Once again, the Veteran is already in receipt of a 100 percent, total combined disability rating from February 25, 2017, including special monthly compensation (SMC) under both 38 U.S.C. §§ 1114 (k) and 1114 (s). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.