Citation Nr: 21067000 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-38 950 DATE: November 3, 2021 ORDER Service connection for an eye disorder is denied. Service connection for a skin disorder is denied FINDINGS OF FACT 1. The Veteran's eye disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. 2. The Veteran's skin disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSIONS OF LAW 1. The criteria for service connection for an eye disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.1. 2. The criteria for service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.1. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 and August 1969. The Veteran contends that he is entitled to service connection for an eye disorder and a skin disorder. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2015 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded the case for additional development, and it now returns to the Board for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (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"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for an eye disorder The Veteran contends that he is entitled to service connection for an eye disorder. Looking at the Veteran's service treatment records (STRs), in a May 1968 treatment note, the Veteran was reported to have a fever of undetermined origin. He developed headaches, eyes hurting, fever, chills, vomiting, and nausea five days prior to admission. The examiner diagnosed the Veteran with a viral syndrome. However, there is no indication in the evidence of record that this resulted in a chronic or long-term disease or disorder related to the eyes. The STRs are otherwise silent for any complaint, diagnosis, or treatment of an eye disease or disorder. In Reports of Medical Examination from December 1966 and August 1969, the examiners marked the Veteran's eyes, ophthalmoscopic condition, pupils, and ocular motility as normal; and the Veteran was reported to have 20/20 vision bilaterally. In the Reports of Medical History from December 1966 and August 1969, the Veteran reported that he had never had any eye trouble. In a December 2003 private annual physical examination, the Veteran reported symptoms of blurred vision and vision flashes and halos. The examiner noted that the Veteran had experienced a contusion to the head a year ago. In a February 2012 VA Primary Care Team Note, the Veteran denied changes in vision, glaucoma, and cataracts. An October 2015 VA Audiology Note stated that the Veteran was having problems with his eyes. An April 2016 VA Primary Secure Messaging Note indicated that the Veteran was using prescription eye drops. In a January 2017 VA Cardiology Consult, the Veteran denied changes in vision, and he reported a history of glaucoma. He stated that he was started on Timolol eye drops by an optometrist last year. In a VA Nursing Outpatient Note from a week later, the examiner noted that the cardiology department had recommended that the Veteran discontinue use of Timolol eye drops because of his bradycardia. The eye drops were discontinued. In an April 2017 VA Cardiology Note, the examiner noted that the Veteran's sinus bradycardia was worse when the Veteran was using the eye drops; and when the Veteran stopped using the eye drops, he could almost immediately tell the difference. In a February 2017 Non-VA Consult, the Veteran was diagnosed with bilateral nuclear sclerotic cataract, bilateral posterior vitreous detachment, glaucoma suspected based on an anatomical narrow angle hyperopia, astigmatism, and presbyopia. In a June 2017 VA Eye Risk Assessment Screening Note, the Veteran presented for glaucoma, and the examiner diagnosed the Veteran with bilateral primary open angle glaucoma (POAG) and bilateral visually significant mixed cataracts. A May 2018 VA Eye Risk Assessment Screening Note stated that the Veteran was a glaucoma suspect bilaterally, and he had somewhat visually significant mixed cataracts bilaterally. In a November 2018 Non-VA Consult, the examiner diagnosed the Veteran with bilateral nuclear sclerotic cortical cataracts and left eye cataract posterior subcapsular. The evidence of record indicates that the Veteran underwent cataract surgery in the left eye in 2018. In a May 2019 Non-VA Consult, the examiner diagnosed the Veteran with left eye iridocyclitis, left eye puckering macula, bilateral pre-glaucoma, and right eye cataracts. In a June 2019 Non-VA Consult, the examiner diagnosed the Veteran with right eye nuclear sclerotic cortical cataracts, left eye pseudophakia, and left eye iritis acute and subacute. A June 2019 Non-VA Note diagnosed the Veteran with bilateral age-related nuclear cataracts. The Board has additionally reviewed the balance of the Veteran's other medical treatment records, and the findings are substantially similar to those noted in the medical evidence described above. There is no other evidence of record showing a causal relationship between the Veteran's eye disorder and his active service. The Board notes that the November 2018 Board decision remanded the issue of service connection for an eye disorder in order to schedule the Veteran for a new VA examination concerning his claimed eye disorder. A March 2021 record indicates that the Veteran requested for the case to be returned as the closest OPH location was 88 miles away, and he was not willing to go more than 10 or 15 minutes from his home. An April 2021 record states that the visual examination was not performed. A May 2021 record concerning the Veteran's visual examination states that the Veteran chose not to travel to the closest provider, which was 88 miles away. The Veteran only wanted to travel 10 or 15 minutes away. The record stated that this was not a quality issue for the examination. Thus, the examination was cancelled. In a July 2021 VA Form 27-0820, VA contacted the Veteran to assess his willingness to report for an examination, and the Veteran stated that he was ready to report for his examination. However, a record from a couple weeks later in July 2021 states that the examination for an eye disorder was cancelled at the Veteran's request. Based on the above, the Board finds that the Veteran did not present good cause for failing to report to the examination for the claimed eye condition. The Board has considered the Veteran's assertions that his claimed eye disorder is caused by or related to his active service. However, the Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter as the nature, etiology, or cause of his eye disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Board finds that the Veteran's assertions as to the etiology of his eye disorder are not competent evidence and, consequently, are afforded no probative weight. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran's eye disorder was caused by, aggravated by, or a result of active service. Consequently, service connection for an eye disorder is not 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, and his claim of service connection for an eye disorder must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to service connection for a skin disorder The Veteran contends that he is entitled to service connection for a skin disorder. As an initial matter, the Board finds that evidence of record reflects that the Veteran has diagnoses of scalp dermatitis and dermatophytosis in the form of onychomycosis of the hands and toenails, as well as bilateral athletic feet, as shown in a January 2021 VA examination. Looking at the Veteran's service treatment records (STRs), in a January 1967 treatment note, the Veteran reported that he was behind a small building or an outhouse that was blown over on him. He felt OK, but later, his body became tense, and he had trouble breathing. Since the accident, he had pain in his collar bone and back, and he had trouble sleeping and pain in his left foot. The examiner observed that the Veteran had a small healing ulceration over the dorsum of the first metatarsal on the left. In a February 1967 treatment note, the Veteran complained of ulceration of the dorsum of the left foot, which had been treated by a corpsman in the field. The ulcer had been present about 10 days ago, and it showed good response to treatment. However, with recent increase in field activity, the healing area had become denuded again, and it had begun to drain pus. The examiner found a superficial ulceration of the dorsum left foot with purulent base, and the examiner gave an impression of a jungle ulcer. The examiner recommended that the Veteran scrub the ulcer with Phisohex followed by a Furacin dressing. He also recommended no prolonged marching, walking, or field activity for five days; but he said the Veteran may stand in lines. In a March 1968 treatment note, the Veteran complained of a sore on his left foot. He had jungle sore dorsum of the left foot one month ago, which healed with conservative treatment. It did well until one week ago on the sweep, and it began a to develop an ulcer in the same location again. The examiner noted that the Veteran's feet were often wet when he was unable to change socks. The examiner found a 1cm deep jungle ulcer on the dorsum of the left foot with purulent base and surround induration and mild tenderness. The examiner gave an impression of a jungle ulcer. The examiner recommended Phisohex soaks followed by Furacin dressing, and he instructed the Veteran to only wear socks and sandals. The examiner also recommended that the Veteran avoid field duty and wearing boots for 10 days. In a July 1969 treatment note, the Veteran complained that he was still having some pain in the dorsum left foot over the area where he had an ulceration in Vietnam. The area had a shiny scar over the vein. The examiner noted that the area may need resection eventually. In Reports of Medical Examination from December 1966 and August 1969, the VA examiners found that the Veteran's skin and lymphatics were normal. The August 1969 Report of Medical Examination noted that the Veteran had a 2-inch scar on the right deltoid. In the August 1969 Report of Medical History, which was from the Veteran's separation examination, the Veteran reported that he experienced occasional pain on the top of his left foot. In Reports of Medical History from December 1966 and August 1969, the Veteran reported that he had not experienced any skin disease. In a November 2003 private annual physical examination, the Veteran was found to have toenail fungus and athletes' foot, and the examiner gave an assessment of onychomycosis of the toenails with tinea pedis. In a November 2011 VA Primary Care Team Note, the Veteran had old hyperpigmented lesions in a dermatome pattern on the left 5th thoracic vertebrae, and a scalp rash was evident. The examiner gave an assessment of tinea caitas and shingles. In a VA Nursing Skin Assessment Note from a couple days later, the examiner found no wounds, pressure ulcers, or other skin problems. In a February 2012 VA Primary Care Team Note, the Veteran was noted to have tinea favosa, and he had no significant skin lesions. He denied changes in skin appearance, moles, rashes, or scars. In a March 2015 VA Primary Care Team Note, the Veteran had ongoing pruritis in his scalp with tinea. The Veteran reported that past medications were of limited help, and he mostly controls his skin condition with over-the-counter products. The examiner noted no pathologic lesions and gave an assessment of tinea. In a May 2015 VA Dermatology Consult, the Veteran complained of a scalp eruption. The Veteran reported decades of pruritic eruption on the scalp with constant itching, pustules, and bumps. He was treated with ketoconazole cream and shampoo a few years ago, which seemed to make it worse. He used a Sulfa-8 ointment with some relief. The Veteran also reported that he had some itching on his feet that began during his tour of duty in Vietnam. The examiner observed that the Veteran's head was shaved and covered in ointment. There was irregular hypertrophic scarring on the occiput and posterior hairline. Ointment was removed from an area, and no scaling or primary lesions were appreciated. The Veteran had several hypertrophic scars on his back and onycholysis on the right great toenail. He also had hyperkeratosis on both plantar feet and the webs of the toes. The examiner gave an assessment of chronic pruritus with keloidal scarring. The examiner stated that there was no evidence of fungal infection, and the Veteran's history was not consistent with tinea capitus, which is very rare in adults without obvious immune suppression. The examiner stated that lichen simplex chronicus or folliculitis keloidalis was more likely. The examiner also gave an assessment of tinea pedis and recommended applying econazole cream to the feet daily. In an August 2015 VA Dermatology Outpatient Note, the Veteran came for a follow up on folliculitis of the scalp and tinea pedis. The examiner noted that all areas had improved, and itching was down to be rated at 2 out of 10. The scalp was clear of active lesions, and there was decreased hyperpigmentation. In a January 2016 VA Dermatology Outpatient Note, the examiner found that the tinea pedis had resolved, and the onychomycosis was stable. The folliculitis of the scalp was well controlled, and there was pruritus of the back with primary lesions. In a January 2017 VA Cardiology Consult, the examiner noted that the Veteran's skin had no discoloration or lesions, and the Veteran denied rash or jaundice. In a February 2018 VA Dermatology Outpatient Note, the Veteran stated that he is doing well, but he found that he needed to use his topical medications regularly to prevent a flare. The examiner stated that the chronic folliculitis and lichen simplex chronicus were much improved and stable. The examiner also found that the Veteran had lateral onycholysis of the right thumb nail, but this may have been secondary to the Veteran's admitted habit of picking at his nails. In a February 2019 VA Dermatology Outpatient Note, the examiner noted that the Veteran's right thumb nail was unchanged, but the Veteran's feet had improved dramatically. In a November 2020 VA Primary Care Telephone Encounter Note, the Veteran complained of a continued itching sensation, but he denied any bleeding or purulent drainage. The Veteran was noted to have dermatitis of the scalp and neurodermatitis with post-inflammatory hyperpigmentation or seborrheic dermatitis. The examiner noted that this condition was less likely to be lichen myxedematosus. The Veteran's main complaint was pruritis and itching. The examiner stated that the Veteran's history was consistent with chronic folliculitis with now residual post-inflammatory hyperpigmentation and pruritis possible due to seborrheic dermatitis. At a February 2021 VA Primary Care Telephone Encounter Note, the Veteran reported improvement of his scalp dermatitis. He had been using triamcinolone ointment mixed with nystatin daily. He reported decreased itching and improvement in the appearance of the scalp with topical ointments. In a May 2021 VA Primary Care Telephone Encounter Note, the Veteran reported that the triamcinolone ointment with nystatin daily seemed to stop working, so he switched to the erythromycin topical and fluocinonide gel with benefit. The examiner gave an assessment of chronic scalp folliculitis that was stable. At a January 2021 VA examination for the Veteran's skin condition, the VA examiner diagnosed the Veteran with scalp dermatitis and dermatophytosis in the form of onychomycosis of the hands and toenails, as well as bilateral athletic foot. The Veteran reported that, after he returned from two tours in Vietnam as a marine, he developed itchy rashes on his feet and hands with nail bed discolorations and thick nails. He also developed periodic scalp rashes with itchiness and bumps. The Veteran had been treated in the past 12 months constantly or near constantly using topical corticosteroids or other immunosuppressive medications, as well as topical ketoconazole. The dermatitis affected between 5 percent and 20 percent of the total body area and less than 5 percent of the exposed body area. The dermatophytosis affected less than 5 percent of the total body area and less than 5 percent of the exposed body area. Regarding the dermatitis of the scalp, the VA examiner observed that there was no visible disease at the time of this examination. Regarding the dermatophytosis with thick and discolored fingers and toenails, the VA examiner observed that there was crusty skin between the toes and foot bilaterally. The Veteran's skin conditions did not impact his ability to work. In a related medical opinion, the VA examiner found that the claimed skin condition was less likely than not (less than 50 percent probability) due to the Veteran's complaints during active service. The examiner stated that this rationale was based on a review of the military medical record showing no complaints, treatment, or diagnosis of the claimed skin condition during service. The examiner stated that the Veteran's separation examination showed no chronic conditions related to the skin and nails, and the examination was normal. The VA examiner found that the Veteran's STRs were silent for scalp skin conditions. The VA examiner acknowledged that there was a March 1968 entry for a jungle ulcer of the left foot, but he found that there was no mention of chronic foot skin or toenail conditions. The examiner also acknowledged that the August 1969 separation examination mentioned occasional pain on the top of the left foot, but the examiner also observed that the separation examination was normal and denied skin conditions. The Board has additionally reviewed the balance of the Veteran's other medical treatment records, and the findings are substantially similar to those noted in the VA examination and other medical evidence described above. There is no other evidence of record showing a causal relationship between the Veteran's skin disorder and his active service. The Board has considered the Veteran's assertions that his claimed skin disorder is caused by or related to his active service. However, the Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter as the nature, etiology, or cause of his claimed skin disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Board finds that the Veteran's assertions as to the etiology of his skin disorder are not competent evidence and, consequently, are afforded no probative weight. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran's skin disorder was caused by, aggravated by, or a result of active service. Consequently, service connection for a skin disorder is not 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, and his claim of service connection for a skin disorder must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Tracie N. Wesner Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.