Citation Nr: 21067721 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 13-22 124A DATE: November 5, 2021 REMANDED Entitlement to service connection for a bilateral eye condition to include cataracts is remanded. REASONS FOR REMAND The Veteran served in the United States Army from March 1964 to March 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision dated in May 2017. This issue was previously before the Board in May 2020 and March 2021, at which time, the issues were remanded to the AOJ for additional development. This case has now been returned to the Board for further appellate action. On remand, and in an August 2021 rating decision, the AOJ granted service connection for major depressive disorder, recurrent (claimed as acquired psychiatric disorder to include posttraumatic stress disorder) with a non-compensable (0 percent) rating effective July 12, 2010, and a 70 percent rating effective August 6, 2021. As the August 2021 decision represents a full grant of the benefits sought with respect to the claim for service connection for major depressive disorder, recurrent (claimed as acquired psychiatric disorder to include posttraumatic stress disorder), this matter is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). 1. Entitlement to service connection for a bilateral eye condition The Veteran seeks service connection for a bilateral eye condition, which he asserts is related to service, including exposure to herbicide agents in service. The Board notes that although the record contains VA opinions regarding the Veteran's bilateral eye condition, the Board finds that it is unable to decide the Veteran's claim based upon the findings of the VA opinions. The Veteran was afforded a VA examination in April 2017, which reflected a diagnosis of bilateral combined cataracts, bilateral large cup to disc ratio, left eye larger peripheral retinal scar, bilateral pinguecula, bilateral conjunctivo chalasis, bilateral arcus senilis, bilateral upper lids dermatochalasis. The examination questions seemed to indicate that the Veteran was service connected for cataracts. However, the Board notes that the Veteran has not been service connected for cataracts. The examiner opined that the additional conditions were unrelated to the Veteran's service-connected diagnosis, cataracts. The examiner did not provide an opinion regarding whether the Veteran's cataracts or the additional diagnoses were directly related to service, which renders the examination inadequate. Pursuant to the May 2020 Board remand, the Veteran was afforded a VA examination in October 2020, which reflected diagnoses of bilateral cataracts, glaucoma, vitreous floaters, corneal arcus, conjunctival chalasis, and chorioretinal scar of the left eye. The examiner opined that it was less likely than not (less than 50 percent probability), that the Veteran's diagnosed eye conditions were incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there was no indication that any of these conditions were affected by or related to his underlying systemic conditions, including diabetes and hypertension. The examiner did not discuss service treatment records which reflect that the Veteran sustained an eye injury in service, and complained of eye pain and irritation, which rendered the examination inadequate. See June 1965 and July 1966 service treatment records. VA obtained an addendum opinion in June 2021, pursuant to the March 2021 Board remand. The June 2021 VA examiner opined that the Veteran's bilateral eye condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner inaccurately noted that the Veteran had been diagnosed with type II diabetes mellitus, and opined that two of the Veteran's eye conditions, cataracts and dermatochalasis, could be related to diabetes, which rendered the examination inadequate. In July 2021, VA obtained an additional addendum opinion, requesting clarification of the June 2021 VA examination. The July 2021 VA examiner opined that if the Veteran was not diabetic, the most common factor related to cataract formation and the presence of dermatochalasis was the aging process. The examiner did not discuss service treatment records which reflect that the Veteran sustained an eye injury in service, and complained of eye pain and irritation, which renders the examination inadequate. See June 1965 and July 1966 service treatment records. Therefore, the Board finds that a supplemental VA opinion is warranted to determine the nature and etiology of the Veteran's bilateral eye condition. The matter is REMANDED for the following action: Obtain a VA addendum opinion from an appropriate examiner to determine the nature and etiology of the Veteran's bilateral eye condition. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, including a copy of this Remand, and the examiner should indicate that the record was reviewed in connection with the examination. Based upon a review of the record, the examiner should address whether it is at least as likely as not (50 percent or greater likelihood) that any current eye condition manifested during service, or that it is otherwise causally or etiologically related to a period of active-duty service, to include exposure to herbicide agents. In rendering the opinions, the examiner must consider and discuss the statements of the Veteran regarding the onset and continuity of the symptoms of his eye condition. The examiner should consider and discuss service treatment records which reflect an eye injury in service, and the Veteran's complaints of eye pain and discomfort during service. See June 1965 and July 1966 service treatment records. The examiner should provide a complete rationale for all opinions expressed and conclusions reached, including a discussion of the facts and medical principles involved. (Continued on the next page) The examiner should note that "in keeping" with the benefit of the doubt rule, which is the standard of proof for veterans benefits, "Congress has not mandated that a medical principal must have reached the level of scientific consensus to support a claim for veterans benefits." Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). Instead, Congress adopted a "low standard of proof" for VA to employ to "resolve a scientific or medical question in the claimant's favor so long as the evidence for and against that question is in 'approximate balance.'" Id. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Johnson 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.