Citation Nr: 21066910 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 16-40 452 DATE: November 2, 2021 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for severe loss of vision in the left eye is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or herbicide exposure, is denied. Entitlement to service connection for a stomach disability, claimed as irritable bowel syndrome (IBS), to include as secondary to service-connected PTSD is denied. Entitlement to service connection for a right hand disability, to include as due to herbicide exposure, is denied. Entitlement to service connection for a left hand disability, to include as due to herbicide exposure, is denied. FINDINGS OF FACT 1. The weight of the evidence does not establish that severe loss of vision in the left eye resulted from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or an event not reasonably foreseeable. 2. Hypertension is not recognized by VA as causally related to exposure to herbicide agents used in Vietnam. 3. The preponderance of the competent and credible evidence of record fails to establish that hypertension manifested in service or within one year of service discharge or that it is otherwise etiologically related to the Veteran's active service (including his in-service exposure to herbicides) and is not caused or aggravated by his service-connected PTSD. 4. The evidence fails to establish an etiological relationship between the Veteran's IBS and his active service or his service-connected PTSD. 5. The Veteran's diagnosed right and left hand disabilities are not recognized by VA as causally related to exposure to herbicide agents used in Vietnam. 6. The preponderance of the competent and credible evidence of record fails to establish that the Veteran's right and left hand disabilities are etiologically related to the Veteran's active service (including his in-service exposure to herbicides). CONCLUSIONS OF LAW 1. The criteria for compensation under 38 U.S.C. § 1151 for severe loss of vision in the left eye due to VA treatment have not been met. 38 U.S.C. §§ 1151, 5103A, 5107; 38 C.F.R. § 3.361. 2. Hypertension was not incurred or aggravated in service and is not related to the service-connected PTSD. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. IBS was not incurred in or aggravated in service, and is not related to the service-connected PTSD. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. A right hand disability was not incurred or aggravated in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. A left hand disability was not incurred or aggravated in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1968 to May 1972, with confirmed service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2011 (hypertension, IBS, hands), and August 2012 (1151) rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). As noted in the July 2019 Board decision/remand, the RO incorrectly considered the claims for his hypertension, hands and 1151 as new and material claims. As already explained in July 2019, the Board has determined that the claims, other than the service connection claim for IBS which was reopened by the Board in July 2019, are not claims to reopen but are to be considered by the Board in the first instance. This case was previously before the Board in July 2019 when the issues listed above were remanded for additional development. An August 2020 supplemental statement of the case was most recently issued and the claims are once again before the Board. 1. Entitlement to compensation under 38 U.S.C. § 1151 for severe loss of vision in the left eye is denied. In order for the Veteran to be eligible for compensation under 38 U.S.C. § 1151 due to VA treatment, the evidence must establish that he sustained additional disability and that this additional disability is etiologically linked to VA treatment by the appropriate standard under 38 U.S.C. § 1151. If there is no competent evidence of additional disability or no evidence of a nexus between the hospitalization, medical or surgical treatment, or examination and the additional disability or death of the Veteran, the claim for compensation under 38 U.S.C. § 1151 must be denied. 38 U.S.C. § 1151 provides that compensation under Chapters 11 and 13 of 38 U.S.C. shall be awarded for a qualifying additional disability or a qualifying death of a Veteran in the same manner as if such additional disability or death were service connected. For the purposes of this section, a disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the Veteran's willful misconduct and: (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary [of VA], either by a Department employee or in a Department facility as defined in section 1701(3)(A) of this title, and the proximate cause of the disability or death was -- (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable; or (2) the disability or death was proximately caused by the provision of training and rehabilitation services by the Secretary (including by a service-provider used by the Secretary for such purpose under section 3115 of this title) as part of an approved rehabilitation program under chapter 31 of this title. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that he has severe loss of vision in the left eye due to VA treatment. He therefore contends that he is entitled to compensation under the provisions of 38 U.S.C. § 1151. This decision is limited to his claim based on 38 U.S.C. § 1151. The Board finds that the weight of the evidence does not establish that the Veteran's current claimed disability is due to VA's carelessness, negligence, lack of proper skill, error in judgment, similar instance of fault, or an event not reasonably foreseeable and that the best evidence in this case provides evidence against this claim. The Veteran was afforded a VA examination and opinions which clearly address this question. An initial February 2012 medical opinion was obtained. The examiner opined that severe vision loss in the left eye is not caused by or a result of VA treatment. The examiner noted that the Veteran experienced a retinal tear/detachment that was treated surgically and without complication to the best he could conclude from all reviewed records. The examiner noted that over the course of the recovery, it appears that the Veteran's visual acuity dropped from 20/30 to around 20/70 at a time about 2 months after the procedure. He noted that he was unable to find records later than August 2010 to understand whether that was the current status of things or if something had changed further. He also noted that there is no evidence that any complication arose from the treatment the Veteran received or that any treatment was unnecessary or performed incorrectly. The examiner stated that it was unfortunate that there was some loss of best-corrected visual acuity in the Veteran's left eye; however, it was not necessarily unexpected that there would be some degree of vision loss involved with this type of microsurgery on the delicate retina. A subsequent June 2013 VA medical opinion was obtained. After reviewing the Veteran's claims file the examiner opined that it is her carefully considered medical opinion that the visual and optical outcome of retinal detachment surgery, despite successful reattachment of a detached retina, is never completely predictable. She noted that in this particular Veteran's situation he underwent extensive surgery to repair a retinal detachment on the left eye that included a pars plana vitrectomy, scleral buckle, Endolaser and air/fluid exchange in June 2010. She noted that although the retina was successfully reattached the Veteran has persistent visual impairment in his left eye which is associated with an epiretinal membrane in the left eye as noted in a September 2010 record by Dr. W.M. and anisometropia as record in September 2010 by Dr. K.B. She stated that these are known complications of retinal detachment surgery that may result in the adverse symptoms that the Veteran complains of despite the successful reattachment of the retina. She further noted that the symptomatic complaints and the physical ocular findings involved in this Veteran's situation are known risks and foreseeable of this type of operative retinal detachment procedure. The examiner recommended that the Veteran be completely reevaluated by a retinal specialist ophthalmologist. The Board remanded the claim in July 2019 to obtain an examination and additional opinion. In a January 2020 report, the examiner noted that the Veteran had been examined in January 2020. He also noted that he had reviewed all of the pertinent evidence of record. The examiner stated that during the examination the Veteran indicated that he was very unhappy with how his original claim was handled. The examiner initially noted that an August 1971 service treatment record noted moderately high myopic astigmatism in the left eye, which itself puts the Veteran at a slightly greater risk of having a retinal detachment. The examiner noted that at the examination the Veteran reported being hit in the left eye as a child with a stick which apparently resulted in the development of a traumatic cataract which was surgically removed in the 1980's. The examiner noted that cataract surgery is also a risk factor for further development of a retinal detachment. The examiner stated that records reflect that the Veteran was seen in June 2010 by the JAHVA Eye Clinic for complaints of sudden loss of lower vision and onset of occasional floaters in the left eye for one week. The Veteran was diagnosed with a retinal detachment of the left eye. Since retinal surgery was not able to be performed that day, he was referred that day to a retinal specialist, Dr. F., close to the Veteran's home. The examiner noted that in a June 14, 2010 letter from Dr. F back to Dr. K at the JAHVA Eye clinic, he explained his rationale (supported by medical studies/literature) as to why initially a pneumatic retinopexy procedure was chosen over a scleral buckle procedure to repair this Veteran's retina. He stated that there were fewer initial risks involved in performing this pneumatic retinopexy procedure, along with the ability to perform scleral buckle procedure if pneumatic retinopexy procedure did not prove to be successful. The examiner then summarized the treatment records that followed after surgery. Initially, it was noted that treatment records in June 2010, July 2010 and August 2010 revealed stable post-operative findings. Subsequently, a September 2010 treatment record noted that the Veteran reported a "horizontal black line" affecting his vision. A September 2011 treatment record continued noting a horizontal black line affecting his left eye vision. A July 2014 treatment record noted the development of a posterior capsule opacification in the left eye status post vitrectomy/scleral buckle. A February 2015 treatment record noted a developing lamellar (partial thickness) hole was diagnosed in the left eye macula. The examiner noted that per medical literature, surgery to repair lamellar holes are not successful. A September 2019 treatment record reflected that there was a slight progression of the lamellar hole in the left eye, but no treatment was recommended based on medical literature. The examiner opined that the Veteran's decrease in visual acuity in the left eye was not caused by and did not become worse as a result of the VA treatment at issue. His retinal detachment in the left eye was diagnosed by the staff of the JAHVA Eye Clinic and he was referred to a retinal surgeon that same day. The examiner noted that he received the most appropriate retinal procedure for his condition that same day also. When the procedure did not prove to be successful for the Veteran, the examiner noted that the treating retinal specialist performed the next appropriate procedure. He noted that the fact that the Veteran's visual acuity in the left eye decreased from 20/70 (one-month post op) to 20/150 (September 2019 and January 2020) was not due to any care received or not, but it can be attributed to the development of a partial thickness (lamellar) retinal hole in his macula, the center of his vision. The examiner noted that medical literature supports the development of lamellar macular holes in patients who have retinal detachments, but also, more frequently, in patients who have not had retinal detachments. Based on the current information, an effective treatment approach for lamellar macular holes has not been definitively determined. The examiner further noted that the additional disability did not result from the attending VA personnel's failure to follow the appropriate standard of care. He noted that the appropriate standard of care was followed by the attending VA personnel from the JAHVA Eye Clinic and the retinal specialist who the Veteran was initially referred to for treatment. The examiner noted that the Veteran was diagnosed, referred, and initially treated all on the same day, June 14, 2010. He noted that the Veteran's retinal detachment was properly treated with pneumatic retinopexy procedure before having to use the vitrectomy/scleral buckle procedure. Additionally, the examiner noted that observation, as opposed to surgery, is the appropriate standard of care in monitoring of a lamellar macular hole which this Veteran has in his left eye. The examiner noted that this is especially true considering he previously had a retinal detachment in this eye and his overall acuity was relatively stable in the left eye with good, more dominant visual acuity in the right eye. The examiner further noted that the Veteran's subsequent need for a second retinal procedure to attach his retina in the left eye in 2010 does not come as a surprise to a reasonable healthcare provider. He noted that even though the medical research/literature supports the initial procedure performed as being the most appropriate one for this Veteran, reasonable healthcare providers realize that not all surgical procures are one hundred percent successful. The retinal specialist involved recognized this fact in his letter dated June 14, 2010 to the JAHVA Eye Clinic outlining what he planned to do if the initial, appropriate procedure was not successful. Likewise, the examiner noted that a reasonable healthcare provider recognizes that lamellar macular holes can occur in patients with and without retinal detachments. The examiner finally noted that the Veteran was diagnosed with a retinal detachment on his initial visit to the JAHVA Eye Clinic. Subsequently, he was referred, and treated, that same day. He concluded that at this time there is not a recognized treatment appropriate that is recommended for a lamellar macular hole, the condition responsible for the Veteran's decreased visual acuity in the left eye. Following a review of the evidence in this case, and the applicable laws and regulations, it is the Board's conclusion that the preponderance of the evidence is against the Veteran's claim for compensation under 38 U.S.C. § 1151 for severe loss of vision in the left eye. The Board has considered the Veteran's statements relating his claimed disability to his June 2010 surgery. He is certainly competent, even as a layman, to comment on things within the perception of his five senses, such as blurriness. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Nonetheless, the Veteran is not competent to opine on questions of causation, negligence, or reasonable foreseeability of medical risks related to his procedure. These determinations are based upon findings that are medically complex in nature and simply not readily amenable to lay comment. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Indeed, contrary to his assertions, the medical evidence, as highlighted by the examiners of record, shows that VA was not careless, negligent, used lack of proper skill, or demonstrated error in judgment, or similar instance of fault. The evidence also shows that the complications claimed by the Veteran were reasonably foreseeable. The Board has also reviewed the internet articles submitted by the Veteran regarding retinal detachment repair (received March 2013). Normally, medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). The Board has considered and weighed such evidence but finds that the internet articles are less probative than the specific medical opinions outlined above. The general internet articles do not address the facts that are specific to the Veteran's case. The Board also points out that the VA opinions specifically addressed and considered the effects of the Veteran's eye surgery. Thus, under these circumstances, the claim for compensation under the provisions of 38 U.S.C. § 1151 must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the competent evidence weighs against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must 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, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element 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). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Additionally, applicable regulations provide that a Veteran who served on active duty in Vietnam during the Vietnam era is presumed to have been exposed to Agent Orange or similar herbicide. 38 C.F.R. § 3.307(a)(1)(6)(iii). The specific statute pertaining to claimed Agent Orange exposure is 38 U.S.C. § 1116. Regulations issued pursuant thereto stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. The diseases that are entitled to presumptive service connection based on herbicide exposure are listed in 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) provides that presumptive service connection based on Agent Orange exposure is available for the following diseases: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; early onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The Veteran had service in Vietnam and exposure to herbicides is conceded. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD. The Board first considers whether the Veteran is entitled to service connection for hypertension on a presumptive basis. Here, however, despite the Veteran's presumed exposure to an herbicide agent during his service in Vietnam, presumptive service connection under 38 C.F.R. § 3.307(a)(6) is still not for application. Service connection is only warranted on this basis for a specific list of diseases set forth under 38 C.F.R. § 3.309(e). As the Veteran's hypertension is not among those listed under 38 C.F.R. § 3.309(e), an award of presumptive service connection based on herbicide exposure is not warranted. Finally, with respect to presumptive service connection under § 3.309(a), in light of the lack of medical evidence reflecting a diagnosis of a hypertension within one year of the Veteran's separation from active service, service connection on a presumptive basis for this disability is also not available. 38 C.F.R. § 3.309. Next, where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the Veteran's hypertension and in-service herbicide exposure or any other incident of active service, or to his service-connected PTSD. Here, the Veteran claims that his hypertension is the result of his service, to include exposure to herbicides, or in the alternative, is caused or aggravated by his service-connected PTSD. Essentially, the Veteran asserts that service connection is warranted under the theories of direct service connection, secondary service connection, and presumptive service connection. As noted above, presumptive service connection is not warranted. The Board will next address the Veteran's contentions that his hypertension is the result of service. However, the evidence does not show a causal relationship between the Veteran's hypertension and in-service herbicide exposure or any other incident of active service. The Veteran's service treatment records are devoid of any instance of treatment for hypertension. In fact, a January 1972 separation examination reflected a normal blood pressure reading. Moreover, in an August 1972 VA examination, completed a few months following separation from service, the Veteran's blood pressure was again recorded as normal. Hypertension was not diagnosed. The Board has considered the totality of the evidence and finds that the weight of the objective clinical evidence is against the Veteran's claim for service connection for hypertension. The Veteran's reported history of continued symptomatology since active service has also been considered but is not found to be accurate. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Notably, post-service treatment records first reflect issues with elevated blood pressure around October 2005. Hypertension was subsequently diagnosed around 2008. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). This long period without problems weighs against the claim. The value of the Veteran's assertions is additionally diminished, given that there is clinical evidence indicating that his blood pressure was normal at the end of his period of active service, and even a few months following separation from service. Accordingly, the Board finds the Veteran's statements asserting continuity of symptomatology of hypertension since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a veteran's statements, it may consider whether self-interest may be a factor in making such statements). Continuity of symptomatology has not here been established, either through the competent evidence or through the Veteran's statements. Having determined that the Veteran's alleged clinical history regarding onset and continuity of hypertension is not consistent with the evidence, the Board next considers that service connection may be granted when the evidence establishes a medical nexus between active service and current complaints. Here, however, the service and post-service evidence provides particularly negative evidence against this claim. The objective medical evidence of record does not establish a link between the Veteran's hypertension and his period of military service, to include his presumed herbicide exposure. The Veteran underwent an initial VA examination in March 2011. He was diagnosed with hypertension. The examiner noted that onset was in the early 2000's. The examiner opined that the Veteran's hypertension is not caused by or a result of his elevated blood pressure reading shown during active duty. She noted that there is but one incidence of documented elevated blood pressure in the service treatment records in 1969 and this was most likely secondary to his acute back pain. The examiner stated that this would have no relationship to the Veteran's later diagnosis of hypertension in the mid-2000's. The Veteran underwent a VA examination in January 2020. The examiner considered an article that the Veteran had submitted from Wikipedia, which included a statement that one of the symptoms of ischemic heart disease is hypertension which has been linked to VA to Agent Orange exposure. The examiner noted that hypertension is a risk factor for ischemic heart disease but has not been separately clearly associated with Agent Orange. The examiner noted that epidemiologic studies have shown an association with Agent Orange with ischemic heart disease but the association with hypertension is limited. He stated that VA recognizes ischemic heart disease as related to Agent Orange. The examiner noted that the Institute of Medicine has looked at hypertension as possibly related to Agent Orange but according to recent information it has reaffirmed prior decisions, and hypertension should be placed in the category of limited or suggestive evidence of association. The examiner concluded that it is less likely that the claim of hypertension is incurred in, and caused by herbicide exposure in Vietnam. There are no contradictory opinions of record. The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and his hypertension. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of his hypertension, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In any event, the probative value of the contentions of the Veteran is outweighed by the medical opinions of record. Thus, the Board finds that the weight of the competent and credible evidence of record is against the Veteran's claim under the theory of direct service connection. The Board will next consider the Veteran's allegations of service connection on a secondary basis. As noted above, service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Veteran underwent an examination in April 2012. He was diagnosed with hypertension. The examiner noted that it is less likely as not that the Veteran's current hypertension is due to or aggravated by his PTSD. The examiner noted that per medical literature review PTSD does not cause or aggravate hypertension. He noted that hypertension is caused by increased peripheral resistance to blood flow mainly attributable to structural narrowing of the small arteries and arterioles. He noted that hypertension is a physiological condition caused by a structural change in the blood vessels and per medical literature the first line of treatment for hypertension is preventative lifestyle changes and includes dietary changes physical exercise, and weight loss. The examiner stated that these have all been shown to significantly reduce blood pressure in people with hypertension. It was note that if hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication. Different programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are advertised to reduce hypertension. However, the examiner stated that in general claims of efficacy are not supported by scientific studies. Hence, he concluded that there is no scientific data showing a direct relationship to hypertension or its aggravation due to psychological stressors. There are no contradictory opinions of record. The Board has also considered the statements made by the Veteran relating his hypertension issues to his service-connected PTSD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of hypertension, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Therefore, after weighing the pertinent evidence of record, the Board concludes that the preponderance of the evidence is against entitlement to service connection for hypertension, as secondary to a service-connected disability. There is simply no competent and probative evidence to support a finding that the Veteran's hypertension has been caused or aggravated by any service-connected disability. The Board has also reviewed the numerous internet articles submitted by the Veteran regarding a potential relationship between hypertension and PTSD, and how exposure to Agent Orange may cause hypertension. Normally, medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). The Board has considered and weighed such evidence but finds that the internet articles are less probative than the specific medical opinions outlined above. The general internet articles do not address the facts that are specific to the Veteran's case, and do not tend to establish a causal relationship between service and the Veteran's hypertension. The Board has also considered the Veteran's contentions in the September 2021 Written Brief Presentation. It is notable that the National Academy of Sciences (NAS) has placed hypertension in the category of "limited or suggestive evidence of an association" with exposure to herbicides. See e.g., Health Effects Not Associated with Exposure to Certain Herbicide Agents, 75 Fed. Reg. 32,540, 32,549 (June 8, 2010). In November 2018, the NAS moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category. The sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to Agent Orange. See Veterans and Agent Orange: Update 2018. The Board notes that even though the NAS has found that there is "sufficient" evidence of an association between hypertension and exposure to herbicides, this does not provide evidence that this Veteran's hypertension is caused by exposure to herbicides. Evidence of an association is not the same as evidence of causation. In conclusion, the Board finds that the preponderance of the evidence is against the entitlement to service connection for hypertension, to include as due to the Veteran's in-service herbicide exposure or his service-connected PTSD. As such, the appeal is denied. 3. Entitlement to service connection for IBS, to include as secondary to service-connected PTSD. The Board will first consider this claim on a secondary service connection basis. The Veteran essentially contends that his IBS is secondary to his service-connected PTSD. In a March 2009 VA examination and opinion, the Veteran was diagnosed with irritable bowel syndrome. The examiner concluded that the Veteran's IBS is not caused by or a result of his PTSD. She stated that per up to date information PTSD has not been found to cause IBS and there is no aggravation of his IBS by his service-connected PTSD. The VA examiner noted that the pathophysiology of IBS remains uncertain. She noted that hereditary and environmental factors are likely to have a role. The examiner stated that many studies have reported abnormal gastrointestinal motility, visceral hypersensitivity, psychologic dysfunction and emotion stress in patients with IBS. Despite intensive investigations, the examiner noted that results have often been conflicting and no physiologic abnormality has been found to be specific for this disorder. An additional April 2012 VA examination and opinion were completed. Although a secondary opinion was obtained, the Board noted inadequacies in this examination in the July 2019 Board remand. As such, little probative value is accorded to the April 2012 opinion. A January 2020 VA opinion was additionally obtained. The examiner noted the Veteran's reports of a bowel problem for about 15 years. He noted that the Veteran described the bowel problem as follows: without warning, he will suddenly have a severe urge for a bowel movement, and then he has a diarrhea-type stool like an explosion. The Veteran reported no abdominal pain associated with this, just a sudden urge. He reported that this happens 1 or 2 times in 30 days and he has a normal bowel movement in between. The Veteran reported that he has never been treated with any medication for this condition and since it occurs so infrequently, he can only recall one physician mentioning one time that this might be IBS. The examiner noted that the Veteran does not meet the criteria for a diagnosis of IBS since he denies abdominal pain and has less frequent episodes than 1 day/week occurrence. The examiner also noted no mention of any explosive diarrhea-type stools or IBS symptoms at the various outpatient visits and that IBS was not listed on the VA problem list. He stated that according to up-to-date medical literature resource, the potential causes of IBS include visceral hypersensitivity, changes in GI motility, post-infectious and alterations in fecal microflora. The examiner noted that some evidence suggests anxiety, PTSD or depression may be factors in some cases. He considered articles that the Veteran had submitted suggesting some association between IBS and a psychiatric disability. The examiner concluded that it is less likely that the Veteran's IBS claim is proximately due to or the result of his PTSD. He also concluded that it is less likely as not that his IBS is aggravated beyond the natural progression by his service-connected PTSD. Although not alleged by the Veteran, the examiner stated that there is no evidence IBS/diarrhea is associated with Agent Orange exposure in Vietnam and it is less likely than not that his IBS is associated with herbicides in Vietnam. The Board finds that the March 2009 and January 2020 opinion are adequate for evaluation purposes. Significantly, the examiners considered the Veteran's history and provided sufficient rationale for the opinions stated. These opinions provide evidence against this claim, making it less than likely such a connection exists. The Board further finds compelling the fact that no probative medical evidence is of record to support a conclusion that the Veteran's IBS was caused or aggravated by his service-connected PTSD. The Board has also considered the statements made by the Veteran relating his IBS to his service-connected PTSD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of IBS, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board has also reviewed the numerous internet articles submitted by the Veteran regarding a potential relationship between IBS and PTSD. Normally, medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). The Board has considered and weighed such evidence but finds that the internet articles are less probative than the specific medical opinion outlined above. The general internet articles do not address the facts that are specific to the Veteran's case, and do not tend to establish a causal relationship between Veteran's IBS and PTSD. Additionally, the January 2020 VA examiner considered these articles. Therefore, after weighing the pertinent evidence of record, the Board concludes that the preponderance of the evidence is against entitlement to service connection for IBS, as secondary to a service-connected disability. The Board notes that in November 2010 and April 2013, the Veteran submitted previous Board decisions for another Veteran who was granted service connection for IBS secondary to a psychiatric disability. The Board notes that Board decisions are not precedential, and "previously issued Board decisions will be considered binding only with regard to the specific case decided." 38 C.F.R. § 20.1303. Each case presented to the Board will be decided based on the individual facts of the case. The Board also considers the theory of entitlement to service connection for IBS on a direct basis. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the claimed disorder and any other incident of active service, as will be discussed below. Service treatment records reflect no treatment for IBS or a stomach disability. A January 1972 separation examination revealed a normal clinical evaluation of his abdomen and viscera. The Board has considered the Veteran's statements regarding continuity of symptoms since service. However, the Federal Circuit has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). As the Veteran's current IBS is not listed under 3.309(a), continuity of symptomatology is simply not applicable in the present case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board nevertheless notes that treatment records do not note treatment for a stomach disability for many years following separation from service. In an August 1972 VA examination, completed a few months following separation from service, the evaluation of his digestive system noted no history of digestive system disease. The Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The service and post-service evidence provide particularly negative evidence against this claim. The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and his IBS. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of IBS, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board acknowledges that a VA medical opinion regarding direct service connection has not been obtained but finds a Remand to obtain a direct service connection opinion is not warranted in this case. A mere conclusory generalized lay statement that service caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). To the extent that the Veteran contends his IBS is generally due to service, there is simply no competent evidence supporting his contention. The evidence of record fails to show IBS or related symptoms during active service; a credible assertion of continuity of related symptoms since service; or competent and credible evidence of record suggesting that the Veteran's currently diagnosed IBS is related to service. Thus, the low standard of McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) has not been met and a VA medical opinion regarding direct service connection is not warranted. Given the foregoing, the Board finds that the medical evidence outweighs the Veteran's contentions to the effect that he has the claimed condition due to his service. Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997). The factual evidence in this case provides significant evidence against this claim. The Board thus concludes that the preponderance of the evidence shows that the Veteran's IBS did not manifest during service, is not otherwise etiologically related to service, and was not caused or aggravated by a service-connected disability. Therefore, the preponderance of the evidence is against the claim for service connection for IBS, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a right hand disability, to include as due to herbicide exposure. 5. Entitlement to service connection for a left hand disability, to include as due to herbicide exposure. The Board first considers whether the Veteran is entitled to service connection for a right hand and/or left hand disability on a presumptive basis. Here, however, despite the Veteran's presumed exposure to an herbicide agent during his service in Vietnam, presumptive service connection under 38 C.F.R. § 3.307(a)(6) is still not for application. Service connection is only warranted on this basis for a specific list of diseases set forth under 38 C.F.R. § 3.309(e). The Veteran asserts that his hand disabilities qualify as a tendon sheath disability (soft-tissue sarcoma) which is listed under 38 C.F.R. § 3.309(e) as a presumptive disability. However, the Board notes that the evidence clearly addresses this contention. In a July 2012 VA examination the Veteran was diagnosed with Dupuytren's contracture of several digits in both hands. The examiner noted that the Veteran has never been diagnosed with a giant cell tumor of the tendon sheaths. He noted that the hand examination reflects a diagnosis of Dupuytren's contracture of the digits, 3, 4, and 5 of both hands and his service treatment records are silent for the claimed condition. The Board remanded the claim in July 2019 for an addendum opinion. A January 2020 examination and opinion were obtained. The examiner noted that the Veteran had been diagnosed with Dupuytren's contracture of the hands/fingers, primarily of the right little finger. The examiner noted that he had undergone several fascial injections which had improved his finger mobility. The examiner stated that the Veteran did not have loss of use of his hands. The examiner also noted that Dupuytren's contracture is due to fibroblastic proliferation and thickening of the palmar fascia, and is not due to deterioration of the tendon sheath. As the Veteran's diagnosed hand disabilities are not among those listed under 38 C.F.R. § 3.309(e), an award of presumptive service connection based on herbicide exposure is not warranted. Next, where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the Veteran's right and left hand disabilities and in-service herbicide exposure or any other incident of active service. Here, the Veteran claims that his right and left hand disabilities are the result of his service, to include exposure to herbicides. As noted above, presumptive service connection is not warranted. Further, the Board notes that the evidence does not show a causal relationship between the Veteran's right and left hand disabilities and in-service herbicide exposure or any other incident of active service. The Veteran's service treatment records are devoid of any instance of treatment for right or left hand disabilities. In fact, a January 1972 separation examination reflected a normal musculoskeletal clinical evaluation. Moreover, in an August 1972 VA examination, completed a few months following separation from service, there was no notation of a right or left hand disability. The Board has considered the totality of the evidence and finds that the weight of the objective clinical evidence is against the Veteran's claim for service connection for a right or left hand disability. The Board has considered the Veteran's statements regarding continuity of symptoms since service. However, the Federal Circuit has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). As the Veteran's current right and left hand disabilities are not listed under 3.309(a), continuity of symptomatology is simply not applicable in the present case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board nevertheless notes that treatment records do not note treatment for his right or left hands for many years following separation from service. As noted above, an August 1972 VA examination, completed a few months following separation from service, made no notation of a right or left hand disability. The Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The service and post-service evidence provide particularly negative evidence against this claim. The objective medical evidence of record does not establish a link between the Veteran's right or left hand disabilities and his period of military service, to include his presumed herbicide exposure. The Veteran underwent a VA examination in January 2020. The examiner noted that according to an up-to-date medical resource website, the etiology of Dupuytren's contracture is multifocal, and important factors include genetics, ethnicity, sex, and age and may include certain environmental factors and other diseases. The examiner noted that this condition is associated also with smoking, alcohol use and diabetes, but there is little evidence of any association with Agent Orange. The examiner noted that Dupuytren's contracture is due to fibroblastic proliferation and thickening of the palmar fascia and is not due to deterioration of the tendon sheath. He opined that it was less likely as not that the Veteran's right or left hand disabilities were incurred in or related to herbicide exposure in Vietnam. There are no contradictory opinions of record. The Board acknowledges that a VA medical opinion regarding direct service connection (not specific to herbicides) has not been obtained but finds a Remand to obtain a direct service connection opinion is not warranted in this case. A mere conclusory generalized lay statement that service caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). To the extent that the Veteran contends his right or left hand disabilities are generally due to service, there is simply no competent evidence supporting his contention. The evidence of record fails to show a right or left hand disability or related symptoms during active service; a credible assertion of continuity of related symptoms since service; or competent and credible evidence of record suggesting that the Veteran's currently diagnosed right or left hand disabilities are related to service. Thus, the low standard of McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) has not been met and an additional VA medical opinion regarding direct service connection is not warranted. The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and his right or left hand disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of his right and left hand disabilities, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In any event, the probative value of the contentions of the Veteran is outweighed by the medical opinions of record. Thus, the Board finds that the weight of the competent and credible evidence of record is against the Veteran's claims under the theory of direct service connection. In conclusion, the Board finds that the preponderance of the evidence is against the entitlement to service connection for a right hand disability or left hand disability, to include as due to his in-service herbicide exposure. As such, the appeal is denied. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. M. Clark, 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.