Citation Nr: 21067508 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 15-42 280 DATE: November 4, 2021 ORDER Service connection for an eye condition, claimed as glaucomatocyclitic crisis, is denied. FINDINGS OF FACT 1. The appellant has current diagnoses of a parafoveal nevus (macular scar) of the right eye, asteroid hyalosis of the right eye, and bilateral cataracts. 2. The appellant served in the U.S. Air National Guard, and had periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) but no periods of active service. 3. The appellant's macular scar of the right eye, which was noted at enlistment as an old, healed choroiditis in the perimacular area, pre-existed his service in the Air National Guard, and was not aggravated during a period of ACDUTRA or INACDUTRA. 4. The appellant had an initial episode of right eye glaucomatocyclitic crisis in February 1970, when he was not in any duty status, and another episode in July 1970, during a period of ACDUTRA; he has not had glaucomatocyclitic crisis during the pendency of this claim. 5. The appellant's current right eye conditions are not linked to disease or injury incurred or aggravated in line of duty during a period of ACDUTRA or INACDUTRA, including the July 1970 episode of glaucomatocyclitic crisis. CONCLUSION OF LAW The criteria for service connection for an eye condition have not been met. 38 U.S.C. §§ 101, 1110, 1131, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served in the U.S. Air National Guard from March 1968 to September 1970, with periods of ACDUTRA from March 10, 1968 to August 2, 1968, July 5, 1969 to July 19, 1969; February 26, 1969 to March 18, 1969, and from July 11, 1970 to July 25, 1970. He also had regular periods of INACDUTRA. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter for further development in July 2019, October 2020, and June 2021. The appellant testified at a hearing before the undersigned Veterans Law Judge in August 2018. A transcript of the hearing is of record. Service Connection Service connection generally will be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link between the current disability and the disease or injury incurred or aggravated in service (the "nexus" element). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021) (holding that if the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise, the claimant receives the benefit of the doubt). Eye Condition The appellant claims service connection for an eye condition diagnosed as glaucomatocyclitic crisis. See June 2012 VA Form 21-526. In this regard, he states that he served as a Munition Specialist, and that he has been told by medical personnel that exposure to ammunition, nitrates, gun powder, and solid propellants can cause that condition. Id.; November 2015 VA Form 9. Because the record shows several diagnosed eye conditions, the Board has expanded the claim to include any such condition reasonably raised by the record, as discussed in its prior remands. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). For the following reasons, the Board finds that service connection is not established for any eye condition. The appellant did not have any periods of active duty service, as defined in 38 C.F.R. § 3.6(a). Rather, he served as a member of the Air National Guard, with periods of ACDUTRA and INACDUTRA, which in itself is not sufficient to establish veteran status. Veteran status must be established as a condition of eligibility for service connection benefits. Bowers v. Shinseki, 26 Vet. App. 201, 206 (2013) (observing that it is "axiomatic that, to receive VA disability compensation benefits, an appellant must first establish veteran status") (citing Cropper v. Brown, 6 Vet. App. 450, 452 (1994)); see 38 U.S.C. §§ 1110, 1131. The fact that a claimant has established status as a veteran for purposes of other periods of service does not obviate the requirement for establishing veteran status for purposes of the period of active duty for training or inactive duty for training on which the claim is based. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). The term "veteran" is defined, in relevant part, as "a person who served in the active military, naval, or air service." 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes: (1) active duty; (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). The term "active duty" means full-time duty in the Armed Forces, other than active duty for training. 38 C.F.R. § 3.6(a). The term ACDUTRA includes, in pertinent part, full-time duty in the Armed Forces performed by Reserves for training purposes, and certain full-time duty performed by members of the National Guard of any State. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). The term INACDUTRA includes duty (other than full-time duty) prescribed for Reserves by the Secretary concerned (as defined under 38 U.S.C. § 101(25)) under 37 U.S.C. § 206 or any other provision of law; special additional duties authorized for Reserves by an authority designated by the Secretary concerned and performed by them on a voluntary basis in connection with the prescribed training or maintenance activities of the units to which they are assigned; and duty (other than full-time duty) performed by a member of the National Guard of any State under 32 U.S.C. §§ 316, 502, 503, 504, or 505, or the prior corresponding provision of law. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(d). Unless and until veteran status is established for any period of ACDUTRA or INACDUTRA, presumptions of service connection generally do not apply to such periods. Bowers, 26 Vet. App. at 206-07 ; Smith v. Shinseki, 24 Vet. App. 40, 45-48 (2010) Donnellan v. Shinseki, 24 Vet. App. 167, 171 (2010); but see Hill v. McDonald, 28 Vet. App. 243, 254 (2016) (holding that the presumption of aggravation applies to periods of ACDUTRA under certain circumstances when veteran status is established with respect to that period). Veteran status has not previously been established for the appellant with respect to any period of ACDUTRA or INACDUTRA. The preponderance of the evidence weighs against incurrence or aggravation of a disease or injury of the eye during a training period that is related to any of the appellant's current eye conditions. The appellant's January 1968 enlistment examination report notes an abnormal clinical evaluation of the ophthalmoscopic system, with a finding of an old choroiditis in the perimacular area in the right eye that was healed. It did not interfere significantly with visual function. The Board notes that a February 1962 private treatment record, dated years prior to enlistment, shows that the appellant was seen in an eye clinic. The record reflects a handwritten notation that is difficult to decipher, but seems to say: "old pig [sic] chorio [sic]." This is followed by a drawing, just beneath which is the word "OD," a medical abbreviation for the right eye. The Board assumes that, in context, this record refers to a condition of the right eye similar or identical to that noted in the January 1968 enlistment examination report, with the abbreviation "pig" meaning pigmented, and the abbreviation "chorio" meaning choroiditis or choroidal. In any event, the January 1968 enlistment examination shows that an old healed choroiditis in the right eye was noted at that time. Private treatment record show that on February 12, 1970, when he was not in any duty status as explained below, the appellant was seen with a complaint of a "film" that had been present in his right eye off and on for the past month. It was worse that day. He denied a history of trauma or serious eye disease. He stated he had been seen at the same clinic eight years earlier and was told at that time that he had a scar in the back of his right eye. Based on an examination and his reported symptoms, he was diagnosed with glaucomatocyclitic crisis. He was prescribed a carbonic anhydrase inhibitor and a topical steroid. A June 1970 private treatment record reflects that the appellant was seen in the eye clinic. The record notes that he had a history of glaucomatocyclitic crisis in the right eye four months ago. Following examination, he was assessed with resolution of that condition, and "no glaucoma." The service treatment records show that on July 21, 1970, during a period of ACDUTRA, the appellant complained of hazy vision. The record notes that he had previously been seen at a private facility for glaucomatocyclitic crisis and treated successfully with medication. He now had similar symptoms. Following examination, the impression was recurrent glaucomatocyclitic crisis in the right eye and a healed chorioretinitis scar in the right eye. A July 1970 letter from the appellant's private treating physician states that the appellant had been under his care since July 21, 1970 for recurrent intraocular inflammation in the right eye, which is known as glaucomatocyclitic crisis. The physician noted the appellant had his first episode of glaucomatocyclitic crisis in February 1970. The physician advised that the appellant could return to his reserve duties provided he be available to be seen by the private clinic every three to four days. A service examination for purposes of medical separation was performed in July 1970. The appellant's eyes were clinically evaluated as abnormal with a diagnosis of glaucomatocyclitic crisis. The report notes the history reviewed above. The service personnel records show that the appellant was discharged from service by reason of a physical disability in September 1970. In an April 1971 letter in support of the appellant's request to be readmitted into the Air National Guard, his private treating physician related that the appellant was seen in February 1970 with elevated intraocular pressure and signs of anterior uveitis, and that a diagnosis was made of either glaucomatocyclitic crisis or glaucoma secondary to anterior uveitis. The physician noted that during the initial attack, the appellant was also found to have a perimacular pigmented lesion in the right eye. According to the letter, the appellant was followed in the clinic, and his pressure remained normal. Occasionally he demonstrated flares in the anterior chamber cells, which indicated a potential for activity but no acute uveitis. In September 1970, according to the letter, he developed "more activities with anterior uveitis." By November 1970, there was no evidence of acute anterior uveitis. A routine examination of the right eye performed in April 1971 showed very mild activity. His intraocular pressure was considered within normal limits. No treatment was started at this visit. The physician summarized that the appellant suffered from acute anterior uveitis of the right eye complicated in one visit with glaucomatous increased intraocular pressure. On all occurrences, the inflammation and glaucoma responded rapidly and quickly to therapy. A January 1974 private treatment record states that the appellant had recurrent episodes of uveitis, and reflects a diagnostic impression of glaucoma secondary to uveitis versus glaucomatocyclitic process. In a January 2013 statement (VA Form 21-4138), a private treating physician specializing in glaucoma wrote that the appellant had recurrent episodes of glaucomatocyclitic crisis documented from February 1970 through January 1974. The physician stated that the appellant was currently seeing her for routine eye examinations and glaucoma monitoring. A December 2014 private treatment record reflects diagnoses of a history of iridocyclitis in both eyes, cataracts in both eyes ("OU"), and a parafoveal nevus/scar. With respect to that last diagnosis, this record notes that photos were taken in August 2011, and that "based on drawings from the 1970[']s" it appeared stable. A December 2016 private treatment record notes a macular scar of the right eye, and under that diagnosis reiterates the finding of a parafoveal nevus/scar that appeared stable based on drawings from the 1970's. A January 2019 private treatment record states that glaucoma was suspected in both eyes "in the context of past uveitis." It also reflects a diagnosis of asteroid hyalosis in the right eye. A September 2020 letter from a private treating physician states that the appellant has a history of glaucomatocyclitic crisis with elevated eye pressure and eye inflammation. He was continually being monitored for the condition. A VA examination was performed in January 2020 as part of the development of this claim. The examiner diagnosed a macular scar affecting the right eye and cataracts affecting both eyes. In the accompanying January 2020 medical opinion, the examiner explained that glaucomatocyclitic crisis is a phenomenon where eye pressure raises above a normal range with an associated uveitis, or inflammation, in the front part of the eye. The examiner noted that the appellant had at least four recurrences of glaucomatocyclitic crisis, with the first being on February 12, 1970. With regard to the appellant's assertion that he was told by a medical professional that glaucomatocyclitic crisis could result from working with munitions and associated exposure to nitrates, gun powder, and propellants during service, the examiner stated that there is some evidence that cadmium, which is used to make ammunition, can play a role in the pathogenesis of glaucoma. However, there was no evidence linking it specifically to glaucomatocyclitic crisis. The examiner added that there is little known about the etiology of glaucomatocyclitic crisis, but that some research showed it may be linked to autonomic dysregulation. Some research related it to allergies, but this was "not a leading theory." Another theory is that it may be due to an underlying immune condition, according to the examiner. There was a chance that some infections may play a role too. The examiner reiterated that there is nothing linking ammunition or cadmium specifically to glaucomatocyclitic crisis, as opposed to open angle glaucoma. In a March 2021 VA medical opinion, the examiner found that the appellant's current eye conditions, including right eye macular scar and bilateral cataracts, are less likely than not related to exposure to ammunition, nitrates, gun powder, and/or propellants, or to his glaucomatocyclitic crisis. The examiner explained that none of these are risk factors for the right eye macular scar or cataracts, which are "at least as likely as not" due to the natural aging process. In a July 2021 VA medical opinion, the examiner noted that the appellant's current right eye parafoveal nevus/scar is also referred to as a macular scar, and found that it is the same condition as shown in the January 1968 enlistment examination report, which was described in that report as a right eye choroiditis, old, in the perimacular area, without significant interference with visual function. The examiner further stated that the February 1970 findings (in the private treatment records) of perimacular pigmented lesions in the right eye referred to a continuation of the same pathology in the macula of the right eye. In a separate July 2021 opinion, the examiner found that it is less likely than not that the appellant's pre-existing macular scar of the right eye underwent a permanent worsening during a period of ACDUTRA or INACDUTRA. The examiner explained that there was no evidence of progression of that condition, and the appellant's vision was still correctable to 20/20 in the right eye. In another separate July 2021 opinion, the examiner found that the appellant's bilateral cataracts and right eye asteroid hyalosis were less likely than not incurred or aggravated during a period of ACDUTRA or INACDUTRA, or any exposure to ammunition, nitrates, gunpowder, or solid propellants during such periods. The examiner explained that these diagnoses were most likely due to natural aging progression. The VA medical opinions are probative, as they represent the conclusions of medical professionals specializing in eye conditions, are based on a recent examination of the appellant (namely the January 2020 examination) and review of his pertinent medical history, and are supported by explanations sufficient for the Board to make a fully informed decision. The Board notes that in its October 2020 and June 2021 remands, it found the January 2020 medical opinion inadequate, and the March 2021 opinion insufficient, and thus remanded for further opinion. However, insofar as the opinions address the issues presented in this matter, they are adequate. The Board did not make a finding to the contrary in its prior remands. Thus, with regard to the January 2020 opinion, although it did not adequately address whether the appellant's current eye conditions are related to service, the Board discerns no inadequacy in its discussion of his history of glaucomatocyclitic crisis and the potential causes of that condition. In its prior remands, the Board did not intimate a find of inadequacy in that respect. In its June 2021 remand, the Board found that the March 2021 opinion did not address whether the appellant's eye conditions were aggravated by in-service exposures as a Munition Specialist, did not consider additional periods of ACDUTRA and INACDUTRA, and did not address the appellant's right eye asteroid hyalosis. However, the Board did not find the March 2021 opinion inadequate so far as it went; instead, the Board found it did not reach all the issues presented. The July 2021 VA medical opinions address those remaining issues. Accordingly, the Board finds that when considered together, the VA medical opinions are adequate to make a fully informed decision, notwithstanding the individual deficiencies of any one opinion in terms of addressing all the issues presented. With regard to the appellant's glaucomatocyclitic crisis, the record shows that it first manifested when the appellant was not in any duty status. More specifically, his first treatment and diagnosis of that condition was on February 12, 1970, which was a Thursday. At that time, he stated his symptom of experiencing a "film" on his right eye had been present off and on for a month. The service department records show that he had a period of INACDUTRA from February 7, 1970 through February 8, 1970, which was the prior weekend. As they do not show he was in any duty status on February 12, 1970, the Board finds that his treatment on that date did on occur during a period of ACDUTRA or INACDUTRA. See Cahall v. Brown, 7 Vet. App. 232, 237 (1994). These records are more probative than his testimony at the Board hearing asserting that it manifested during a weekend drill training in February 1970, as they constitute direct evidence in the form of official records. Accordingly, as the service department records conflict with the appellant's testimony, the Board finds that it is not credible in its assertion that his glaucomatocyclitic crisis first manifested during a weekend drill training in February 1970. (It is possible that, in his hearing testimony, the appellant actually was remembering the July 1970 episode during the ACDUTRA period.) Moreover, the February 1970 record states that the appellant reported a one-month history of his symptoms, which indicates they would have first manifested some time in January 1970. In sum, the appellant's glaucomatocyclitic crisis did not have its initial onset during a period of ACDUTRA or INACDUTRA. The second episode of glaucomatocyclitic crisis occurred in July 1970, during a period of ACDUTRA. While no medical opinion has addressed whether this represents permanent aggravation of a pre-existing condition beyond natural progression, there is no indication in the record that it was other than one of several episodes of glaucomatocyclitic crisis that occurred before and after that training period. Whatever the case may be, the record shows that the appellant has not had glaucomatocyclitic crisis during the pendency of this claim. The VA medical opinions constitute probative evidence that his current eye conditions are not related to the prior episodes of glaucomatocyclitic crisis, as this is not a risk factor for those conditions. Rather, they have been attributed to the natural aging process. The appellant's statement that he has been told his glaucomatocyclitic crisis may be due to exposures to ammunition, nitrates, gun powder, and solid propellants associated with his duties as a Munitions Specialist is competent evidence. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, it is not sufficient to establish the fact, as he may have misrepresented, misunderstood, or misremembered what he was told. The January 2020 VA medical opinion explains that exposure to cadmium, which is an ingredient in ammunition, may play a role in the pathogenesis of glaucoma; however, the examiner found that there is no evidence linking such exposure to glaucomatocyclitic crisis, which is a distinct condition with other potential, if inconclusive, causes. The January 2020 medical opinion outweighs the appellant's unsupported assertion that he was told his glaucomatocyclitic crisis may be due to environmental exposures as a Munitions Specialist. Unlike the appellant's statement, the January 2020 medical opinion constitutes direct medical evidence, and is supported by an adequate explanation on that issue. By contrast, the appellant's statement is too unreliable to be sufficient evidence to establish such a relationship, as just explained. Accordingly, the preponderance of the evidence weighs against a finding that the appellant's glaucomatocyclitic crisis was incurred or aggravated during a period of INACDUTRA or INACDUTRA, or caused by any in-service environmental exposures as a Munitions Specialist. In the alternative, regardless of whether the appellant's glaucomatocyclitic crisis may have been incurred or aggravated during a training period, the probative evidence shows he has not had this condition during the period under review. While he has been monitored for potential glaucoma due to his history of uveitis, he has not been diagnosed with either glaucoma or glaucomatocyclitic crisis. In the March 2021 VA medical opinion, the examiner found that the appellant's currently diagnosed bilateral cataracts, right eye asteroid hyalosis, and parafoveal nevus (macular scar) of the right eye are not related to his glaucomatocyclitic crisis or to exposure to ammunition, nitrates, gun powder, and/or solid propellants. The examiner explained that these are not risk factors for the appellant's current eye conditions, which are "at least as likely as not" due to the aging process. In context, the examiner clearly meant that the appellant's eye conditions are more likely related to the aging process, as stated in the July 2021 medical opinion. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"). In any event, the examiner clearly and sufficiently explained why they are not related to service, which is all that is needed for purposes of determining whether the criteria for service connection have been met. Finally, with regard to the parafoveal nevus or macular scar, the July 2021 VA opinion found that this is the same condition as noted in the January 1968 enlistment examination report. Accordingly, the probative evidence shows it pre-existed service. The examiner also found that it was not aggravated during or by any period of ACDUTRA or INACDUTRA, as there was no evidence of any progression such as vision changes. The Board notes that the private treatment records dated in December 2014 and December 2016 found it to be stable when comparing images taken in 2011 with drawings from the 1970's. Accordingly, the preponderance of the evidence shows it was not incurred or aggravated during a period ACDUTRA or INACDUTRA, or aggravated by any disease or injury incurred or aggravated during such a period. In sum, the appellant's current eye conditions are not linked to disease or injury incurred or aggravated during a period of ACDUTRA or INACDUTRA. Consequently, the criteria for service connection have not been met. See Holton, 557 F.3d at 1366. As the preponderance of the evidence is against the claim, there is not an approximate balance of positive and negative evidence and, therefore, the benefit-of-the-doubt rule does not apply. See Lynch, 999 F.3d at 1395; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 U.S.C. § 5107. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.