Citation Nr: 21068696 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 17-00 760 DATE: November 12, 2021 REMANDED Entitlement to service connection for an eye disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1988 to July 1991 and from October 1992 to October 1995. This matter comes before the Board of Veterans' Appeals (Board), on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously considered this appeal in January 2019 and remanded this issue for further development including scheduling a VA examination. The case returned to the Board for further appellate review. 1. Entitlement to service connection for an eye disability is remanded. Unfortunately, the Veteran's claim for service connection for an eye disability must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's appeal so that he is afforded every possible consideration. First, the Board finds that remand is warranted in order to comply with the January 2019 Board remand instructions for the requested VA examination and opinion. The Veteran was afforded a VA examination in August 2020. The examiner noted diagnoses of dermatochalasis of upper eyelids, blepharitis of eyelids OU, corneal scars OU, glaucoma suspect, due to optic nerve cupping OU; pavingstone degeneration OD and bear tracking of peripheral retina OS, photophobia OU. The examiner opined that the Veteran's eye disability is not related to service. The rationale provided is that "[t]here is no evidence of trauma or chronic eye disease prior to or during service evidenced by entry and exit examinations. The patient reports suffering from photophobia since 1991 (per last eye exam note in 2013). While it could be related to sun exposure, photophobia has a number of causes including medication use, corneal scars, blepharitis, etc. Therefore, it is impossible to determine if sunlight during service is the one and only cause of the patient's photophobia." The examiner also stated that the photophobia experienced by the Veteran could be multifactorial. "While it could be related to sun exposure in the past, it could also be from his mild blepharitis and corneal scarring or from the medications the patient is taking. There is no way to directly prove the sun exposure caused the photophobia as there was no previous history in the record of this eye condition when in service. The dermatochalasis is often an age-related finding. Corneal scars, blepharitis, optic nerve cupping, and retinal degeneration have no correlation to service as there was no trauma and are incidental findings." In January 2021, an addendum opinion was added to the record, the same examiner stated that "[p]hotophobia can be multifactorial. It could be the results of blepharitis or medication use for example. There is not sufficient evidence to say the photophobia is the direct result of sun exposure during service. The other examination findings are incidental findings. The glaucomatous cupping could be genetic in nature. Blepharitis is a common exam finding and affects certain skin types more than others. The corneal scar in the left eye could have been from a previous injury or object in the eye. Finally, the bear tracking is also an incidental finding that can be idiopathic or has links to possible colon issues such as polyps." Where VA provides the veteran with an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In this case, the VA examiner appeared to provide a negative nexus opinion concerning the Veteran's eye disability; however, she provided a confusing rationale with conditional language and appears to be applying an incorrect standard. 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. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (An "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). The examiner noted he could not prove causation or that the condition was a direct result of exposure and cites to the multifactorial nature of the condition. This implies he is using an incorrect standard as all that is needed is that it is at least as likely as not that the condition is related to service. Additionally, the examiner noted the Veteran's photophobia was not related to service, though "it could be related to sun exposure in the past". A speculative medical opinion as to causation cannot establish a medical nexus to service. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Based on the foregoing, a clarifying opinion must be obtained. Further, the VA examiner has not addressed the Veteran's contentions, in addition to sun exposure, that the dry, arid, and dusty smoke-filled conditions in the Persian Gulf caused his diagnosis of "dry eye" and photophobia. See December 2016 VA Form 9. The Board finds these opinions are inconclusive and therefore are not adequate for adjudicating purposes. Thus, a remand for an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Associate any outstanding VA treatment records with the electronic claims file. 2. After completing the records development indicated above, obtain an addendum opinion by an appropriate clinician to identify and determine the nature and etiology of any eye disorder. The examiner must opine whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's current eye disorders are related to an in-service injury, event, or disease. The examiner should also opine on whether any of the Veteran's eye disorders had their onset in service. The examiner is asked to specifically consider the Veteran's statement about the dry, arid, and dusty smoke-filled conditions when he served in the Persian Gulf, and his assessments of dry eye and photophobia. See December 2016 VA Form 9. The examiner must also consider and discuss the Veteran's contention that he was not taking any medication in 1991, when the record shows that his eye condition began. See August 2021, Appellate Brief. (Continued on the next page) The examiner is reminded that a definite cause is not required, nor is it required that the eye condition is more likely related to service than some other non-service-related cause. Rather we need to determine whether his eye condition is just as likely related to service as some other cause. A complete rationale should be provided for any opinion provided. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Romero-Sanchez, 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.