Citation Nr: 21066000 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 17-19 102 DATE: October 28, 2021 ORDER Entitlement to service connection for a bilateral eye condition, to include bilateral cataracts, is denied. Entitlement to service connection for valvular heart disease (including rheumatic heart disease) is denied. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities prior to February 11, 2014, is denied. FINDINGS OF FACT 1. The Veteran's bilateral eye condition is not related to his military service. 2. The Veteran's valvular heart disease (including rheumatic heart disease) is not related to his military service. 3. Prior to February 11, 2014, the Veteran was not unemployable by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral eye condition, to include bilateral cataracts, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for valvular heart disease (including rheumatic heart disease) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Prior to February 11, 2014, the criteria for a TDIU have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from November 1948 to April 1949. This matter comes before the Board of Veterans' Appeals (Board) from the May 2015 and August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a July 2019 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. SERVICE CONNECTION 1. Entitlement to service connection for a bilateral eye condition, to include bilateral cataracts The Veteran contends that his bilateral eye condition is related to his military service. He testified during the hearing held in May 2019 that he had a heart attack in service due to his gas mask and it affected his eyes. He also reported having eye infections. The Veteran's service treatment records are not available as they were destroyed by fire. As noted above, this matter was previously before the Board in June 2021 and was remanded for further development. Specifically, one of the Board's remand directives was to obtain addendum opinions regarding the Veteran's claimed conditions. In September 2020, the Veteran underwent an eye examination. The examiner noted that the Veteran is diagnosed with left eye asteroid hyalosis, bilateral nuclear sclerotic cataract, and bilateral cortical cataract. The examiner stated that a cataract is a clouding of the natural intraocular crystalline lens that focuses the light entering the eye onto the retina. The examiner noted that this cloudiness can cause a decrease in vision and may lead to eventual blindness if left untreated. Additionally, the examiner stated that cataracts often develop slowly with a gradual decline in vision that cannot be corrected with glasses. The examiner also stated that a drooping eyelid is called ptosis or blepharoptosis. Ptosis is noted as the upper eyelid falls to a position that is lower than normal and may be present at birth or develop later in life. Asteroid hyalosis was noted as a clinical entity in which calcium-lipid complexes are suspended throughout the collagen fibrils of the vitreous. However, the examiner did not provide any rationale why these conditions are not related to the Veteran's military service. Subsequently, in February 2021, another medical opinion was obtained. The examiner stated that a review of the records reveals that the Veteran has bilateral cataracts. The examiner opined that the Veteran's current bilateral cataracts are at least as likely as not a continuation of the bilateral cataracts that were noted in a 2015 eye examination and are due to normal aging progression. However, the examiner did not provide any explanation as to why the Veteran's cataracts that were documented in 2015 were not related to his military service. Additionally, the examiner did not discuss any of the other diagnoses that the September 2020 VA examination and whether or not they are related to the Veteran's military service. Pursuant to the Board's June 2021 remand, an addendum opinion was obtained in August 2021. The examiner opined that it is less likely as not that any of the Veteran's bilateral eye conditions are related to his military service. The examiner explained that the Veteran's cataracts were diagnosed in 2015, which were many years after the Veteran's time in service and are due to the natural aging progression. The examiner stated that the Veteran's other diagnoses were also after the Veteran's time in service and were also most likely due to natural progression in time. Therefore, the Board finds that the medical and lay evidence of record does not demonstrate that entitlement to service connection for a bilateral eye condition is warranted. In reaching the above conclusions, 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 in the instant appeal. See 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for valvular heart disease (including rheumatic heart disease) The Veteran contends that his heart condition is related to his military service. Specifically, the Veteran contends that he suffered a heart attack during his military service. In the Board's June 2021 remand, it found that a remand was warranted to obtain an addendum opinion to determine the etiology and potential nexus between the Veteran's heart condition and military service. In August 2020, the Veteran underwent a VA heart conditions examination. The Veteran was noted to be diagnosed with acute, subacute, or old myocardial infarction, coronary artery disease, valvular heart disease, aortic stenosis, status post aortic valve replacement, and atrial fibrillation. The examiner opined that the Veteran's heart conditions are less likely than not related to his military service. The examiner stated that there is documentation of the Veteran having a heart attack in service as noted in the Board's June 2020 remand. However, the examiner stated that the Veteran is not very clear about the treatment he received. The examiner stated that there is documentation that the Veteran had a myocardial infarction in 2011, had a stent placement in 2014, diagnosis of aortic stenosis in 2015, and a valve replacement in August 2018. The examiner stated that the common clinical finding in aortic stenosis is presence of a murmur even in asymptomatic patients. However, the examiner noted that the Veteran does not have any documentation of having a heart murmur in service. The examiner also cited an October 2016 echocardiogram that showed severe aortic stenosis with a degenerative aortic valve and an August 2020 echocardiogram that reported normal ejection fraction, aortic valve calcification, and other valvular lesions. The examiner stated that in aortic stenosis, the opening of the aortic valve becomes narrowed or constricted. Additionally, the examiner noted that there are inconsistent reports about the Veteran's first heart attack. Therefore, the examiner opined that the Veteran's aortic valve stenosis and aortic valve replacement is less likely than not due to the Veteran's military service. Furthermore, the examiner stated that the Veteran's diagnoses of coronary artery disease, history of myocardial infarction, history of atrial fibrillation, and valvular heart disease are less likely due to any service incident. Based on these statements, the examiner stated that the Veteran's current conditions are less likely than not incurred in and/or caused by the Veteran's military service, to include being exposed to increased amounts of poisonous gas and cigarette smoke. However, the Board found this opinion inadequate as it merely provided information about the Veteran's current diagnoses and did not provide an adequate rationale as to why these conditions are not related to his military service. Therefore, in March 2021, another cardiac opinion was obtained. The examiner stated that the Veteran has aortic valve stenosis which is due to degeneration of the valve due to the aging process. Additionally, the examiner stated that the Veteran's valvular heart disease is not due to rheumatic origin and is due to aging and degeneration. The examiner also reported that there are no records of heart disease in childhood or during the Veteran's military service, or any exposure to chemicals noted. Therefore, the examiner concluded that the claimed cardiac conditions are less likely than not related to the Veteran's military service, to include exposure to increased amounts of poisonous gas and cigarette smoke during service. However, again, the March 2021 examiner did not adequately explain why the Veteran's cardiac conditions are not related to service, to specifically include exposure to increased amounts of poisonous gas and cigarette smoke. Therefore, an addendum opinion was requested. Pursuant to the Board's June 2021 remand, an addendum opinion was obtained in August 2021. The examiner stated that the Veteran is diagnosed with coronary artery disease, prior myocardial infarction, valvular heart disease (aortic stenosis), status post aortic valve replacement, and atrial fibrillation. The examiner opined that the Veteran's heart conditions are less likely than not caused by his military service, to include the Veteran's claimed reported exposure to increased amounts of poisonous gas and cigarette smoke during military service. The examiner stated that the Veteran's infarction was diagnosed in August 2011, at which time he suffered a cardiac arrest, had successful CPR, and was admitted to the hospital. The Veteran was diagnosed with mild aortic stenosis. In February 2014, during a hospital admission, an echocardiogram documented that the aortic stenosis had progressed to moderate-severe and subsequent echocardiograms documented progression to severe aortic stenosis. In 2018, the Veteran underwent aortic valve replacement. The examiner noted that all of the Veteran's cardiac conditions were diagnosed more than 60 years following his discharge from military service. The examiner noted that cardiovascular disease is common in the general population, affecting the majority of adults past the age of 60 years. Additionally, the examiner stated that degenerative (calcific) aortic stenosis valve disease is a common valvular condition encountered among older persons and the prevalence of aortic stenosis increases with age. The examiner stated that the risk factors associated with the development of degenerative aortic stenosis in older adults are similar to those for atherosclerosis. The Veteran's risk factors for degenerative aortic valve stenosis include: older age (Veteran was 79 years old when first found to have aortic stenosis), male gender, current cigarette smoker, and diagnosed with hypertension. The examiner stated that the Veteran's risk factors for coronary artery disease included being a cigarette smoker (up to 2 packs a day for over 70 years), dyslipidemia/hyperlipidemia, advanced age, male sex, hypertension, and overweight/obesity. Regarding secondhand cigarette smoke, the examiner stated that this can increase the risk of coronary artery disease. However, the degree (amount and concentration) of secondhand smoke exposure the Veteran may have had during active duty service is unknown. Additionally, the provided evidence of record contained no clinic treatment records immediately following service, nor within 20-30 years following military service documenting coronary artery disease. Therefore, the examiner concluded that the Veteran's personal history of cigarette smoking of up to 2 packs per pay for over 70 years is a greater risk factor for coronary artery disease. Regarding atrial fibrillation, the examiner stated that hypertensive heart disease and coronary heart disease are the most common underlying disorders in persons with atrial fibrillation. Additionally, almost any valvular hear disease condition that leads to significant stenosis or regurgitation is associated with the development of atrial fibrillation. The examiner noted that the Veteran's underlying conditions (severe aortic stenosis and coronary artery disease) place him at risk for development of atrial fibrillation. The examiner stated that secondhand cigarette smoke was not found as a risk factor for atrial fibrillation and a review of coronary artery disease, aortic stenosis, and atrial fibrillation did not identify any poisonous gases as risk factors for the development of the conditions. Therefore, the Board finds that the medical and lay evidence of record does not demonstrate that entitlement to service connection for a cardiac condition is warranted. In reaching the above conclusions, 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 in the instant appeal. See 38 U.S.C. § 5107 (b). 3. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service connected disabilities prior to February 11, 2014 The Veteran seeks a TDIU prior to February 11, 2014. An April 2021 rating decision granted entitlement to a TDIU beginning February 11, 2014, the date the Veteran met the schedular criteria. However, the April 2021 grant of benefits was only a partial grant of benefits and the Veteran's claim of entitlement to a TDIU prior to February 11, 2014 remains on appeal. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3)disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. The Veteran has the following disabilities that are service connected: bilateral hearing loss (rated 40 percent, from September 25, 2013 to May 12, 2016; rated 50 percent from May 13, 2016 to August 9, 2020; and rated 60 percent from August 10, 2020 to the present); tension headaches (rated 50 percent from February 11, 2014 to the present); and tinnitus (rated 10 percent from September 25, 2013 to the present). His combined rating was 50 percent from September 2013, 70 percent from February 11, 2014, and 80 percent from May 13, 2016. Individual unemployability has already been recognized from February 11, 2014. Based on the forgoing, the Veteran does not meet the percentage standards set forth in § 4.16(a) prior to February 11, 2014. Therefore, the Board may not consider his claim for a TDIU prior to February 11, 2014, in the first instance but will refer it to the Director, Compensation Service, if it is shown that he is unemployable by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). As described in Ray v. Wilkie, the correct standard for referral is whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities." 31 Vet. App. 58, 66 (2019). The Board finds that there is not sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable by reason of his service-connected disabilities, and therefore referral of the claim is not warranted. The Veteran's highest level of education is seventh grade. As stated on his June 2015 application for unemployment that he hadn't worked in the last five years. The Veteran's ability to secure and follow a substantially gainful occupation is impacted by the physical effects of his cardiac condition, hearing loss, and headaches. Specifically, the Veteran stated that he has chest pains and shortness of breath. Additionally, numerous medical records, including a July 2017 record, state that the Veteran is unemployable to due to his age and cardiac conditions. However, the Veteran is not service connected for a cardiac condition. Additionally, age is not a factor to be considered in determining entitlement to a TDIU. Given the forgoing, there is not sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable by reason of his service-connected disabilities. Specifically, the evidence of record does not demonstrate that the Veteran's service-connected disabilities manifested to a degree to interfere with his ability to maintain or secure employment. Accordingly, referral of the claim for a TDIU is not warranted. A TDIU is denied. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mountford, 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.