Citation Nr: 21069204 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 16-35 119 DATE: November 17, 2021 ORDER Service connection for bilateral knee disability, to include osteoarthritis, is denied. Service connection for bilateral ankle disability, to include osteoarthritis, is denied. Service connection for left eye cataract is denied. Service connection for diabetic retinopathy of left eye is denied. REMANDED Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. Service connection for photophobia of left eye is remanded. FINDINGS OF FACT 1. The Veteran's bilateral knee disability was not manifest during active service, and is not attributable to service or caused or aggravated by a service-connected disease or injury. 2. A left ankle sprain in active service was acute and transitory, and right ankle disability was not manifest during active service; the Veteran's bilateral ankle disability is not attributable to service or caused or aggravated by a service-connected disease or injury. 3. The Veteran's left eye cataract was not manifest during active service and is not attributable to service. 4. The Veteran's diabetic retinopathy of left eye was not manifest during active service and is not attributable to service or caused or aggravated by a service-connected disease or injury. CONCLUSIONS OF LAW 1. Bilateral knee disability, to include osteoarthritis, was not incurred in or aggravated by service; and is not proximately due to or a result of service-connected disease or injury. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Bilateral ankle disability, to include osteoarthritis, was not incurred in or aggravated by service; and is not proximately due to or a result of service-connected disease or injury. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. Left eye cataract was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Diabetic retinopathy of left eye was not incurred in or aggravated by service; and is not proximately due to or a result of service-connected disease or injury. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1973 to January 1976. He timely appealed these matters from March 2014 and September 2015 rating decisions of the Agency of Original Jurisdiction (AOJ). In January 2019, the Veteran withdrew his prior request for a hearing before the Board of Veterans' Appeals (Board), in writing. In a January 2020 decision, the Board denied service connection for bilateral knee disability and denied service connection for bilateral ankle disabilityto include each as secondary to service-connected disease or injuryon its merits; and remanded the matters of service connection for left eye disability, for bilateral hearing loss, and for tinnitus for further development. The Veteran appealed the January 2020 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2021 Joint Motion for Partial Remand, the parties moved to vacate the Board decision to the extent that it denied service connection for bilateral knee disability and for bilateral ankle disability. The Court granted the motion. Thereafter, the appeal was returned to the Board. In April 2021, the AOJ issued a supplemental statement of the case (SSOC), reflecting the continued denial of service connection for left eye disability, for bilateral hearing loss, and for tinnitus. In a June 2021 decision, the Board granted service connection for lumbar spine disability; and remanded the matters of service connection for bilateral knee disability, bilateral ankle disability, left eye disability, bilateral hearing loss, and tinnitus for further development. In August 2021, the AOJ granted service connection and assigned a 10 percent evaluation for bilateral plantar warts; and granted service connection and assigned a 0 percent (noncompensable) evaluation for penile warts. Each award was effective from April 6, 2015. As the record, to date, reflects no disagreement with either the initial ratings or the effective date assigned, it appears that the grants of service connection have resolved those matters; they are no longer before the Board. Here, substantial compliance with the Board's January 2020 and June 2021 remand orders is demonstrated for decided claims. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). All available records identified by the Veteran as relating to each of his claims decided below have been obtained, to the extent possible. The record does not otherwise indicate any existing pertinent evidence that has not been obtained. Examination reports and opinions are thorough and adequate for the Board to render the following decisions in the Veteran's appeal. 38 U.S.C. § 5103A(a)(2). Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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, 1167 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some chronic diseases, such as arthritis and organic diseases of the nervous system, may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). The applicable presumptive period is one year from separation. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). In this case, the Veteran was presumed sound at service entry. Clinical evaluation at entry in October 1973 was normal, and no disability was recorded. Nor is there medical evidence of any disability prior to active service. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Bilateral Knee Service treatment records do not reflect any findings or complaints of knee problems or trauma to either knee. There is no evidence of treatment in active service for bilateral knee disability. Arthritis of bilateral knee was not demonstrated in active service or within the first post-service year. Therefore, the in-service element has not been met. Rather, post-service records, dated in November 2011, show complaints of bilateral knee pain, right greater than left, from one year ago, which gradually occurred. Pain was described as aching and localized over the knee joint. Pain was worse with any weight-bearing and worse with activity. Examination in November 2011 revealed that the Veteran had an abnormal gait. There were full ranges of motion and no effusion; ligamentous structures were intact. Straight leg raising was negative, but with pain in low back on the right. X-rays of knees were normal. The assessment in November 2011 was bilateral knee pain most likely due to mild knee osteoarthritis, versus inflammatory knee arthritis. Physical therapy was provided. In September 2013, the Veteran reported having chronic knee pain. There is an assessment of osteoarthritis in November 2012, based on history and physical consistent with osteoarthritis. The Veteran complained of bilateral knee pain; X-rays were ordered. In May 2014, the Veteran reported that his knees felt weak. There is an assessment of bilateral knee pain in June 2015. There was no history of knee trauma. X-rays of left knee in March 2016 revealed diffuse soft tissue swelling of knee; no periosteal reaction or bone erosion was noted. The knee joint space was within normal limits; no fracture or dislocation was seen. There was no radiographic evidence of any bony or soft tissue pathology. In April 2016, the Veteran reported that he fell on his left knee about two months ago and the knee still hurt. Limited ranges of motion and left knee edema were noted. Imaging at the time revealed prepatellar tendon bursitis of left knee. The Veteran reportedly stopped working due to pain in his knees and ankles. In this case, there is a gap of decades between the Veteran's separation from active service in 1976 and records documenting any bilateral knee disability. The evidence does not reveal any bilateral knee disability during active service, or that arthritis of either knee manifested within one year after the Veteran's separation from active service in January 1976. As such, he is not entitled to direct or presumptive service connection. While the Veteran is competent to describe his symptoms, the evidence does not reveal any disease or injury of either knee during active service. The Veteran specifically denied any arthritis, rheumatism, or bursitis; and denied any bone, joint, or other deformity in active service. Even assuming the Veteran was treated for recurrent knee pain at times, there is no evidence of chronicity of care following active service. An alternative route to direct service connection for bilateral knee disability, to include osteoarthritis, is not demonstrated. Walker, 708 F.3d at 1338-39. The Veteran also contends that his bilateral knee disability is secondary to service-connected lumbar spine disability with degenerative joint disease. He still complained of bilateral knee pain in November 2018; knee braces were replaced. During a physical therapy consultation in December 2018, the Veteran reported that his knees swell and hurt all the time; and that he used a cane for about five or six years. Active ranges of motion of each knee were guarded. The physical therapist noted signs and symptoms of chronic low back pain and knee pain and ankle pain from degenerative disc disease, as noted with X-rays. In February 2021, the Veteran reported pain persisting for over twenty years; and that pain was in his lower back and in both knees. The physical therapist noted signs and symptoms of chronic low back pain and knee pain, possibly caused by chronic inflammatory responses from poor muscle imbalances and arthrokinematics; and indicated that this could cause muscular guarding and restrictive circulation in the lumbar spine and knees, resulting in the pain the Veteran experienced. Physical therapy goals were to reduce pain in lower back and knees. In April 2021, the Veteran contended that his lumbar spine disability"being the way that it is"negatively affected his knees; and reportedly was told by doctors that his lumbar spine condition made his bilateral knee pain worse, and he could no longer work. In June 2021, a VA social worker noted an appropriate diagnosis of bilateral knee brace replacement; and listed the reason for request as knee pain, and limitations and/or precautionsi.e., osteoarthritic knees. A July 2021 VA examination report reveals a diagnosis of prepatellar tendon bursitis of left knee and a diagnosis of right knee strain. The Veteran reported a medical history of injuring his knees running during physical training and carrying heavy equipment and supplies as an infantry man in active service. The course since onset had progressively worsened, and current symptoms included pain and stiffness and swelling. The Veteran reported no flare-ups. He did report bilateral knee difficulty with bending, climbing up and down stairs, with prolonged walking, standing, and sitting. He also reported swelling of each knee. The Veteran recently retired as a traffic light technician and reported losing from one-to-two weeks of work in the last 12 months due to bilateral knee pain. Following examination in July 2021, the examiner opined that it was less likely than not that the Veteran's bilateral knee disability was proximately due to or the result of the Veteran's service-connected lumbar spine disability with degenerative joint disease. In support of the opinion, the examiner reasoned that MRI scans confirmed a knee injury by falling in 2016; and explained that there was no clear evidence in the orthopedic literature to suggest an injury to one joint would have any significant impact on another or opposite uninjured joint or limbunless injury resulted in major muscle or nerve damage causing partial or complete paralysis, or shortening of injured limb resulting in leg length discrepancy of more than 5 centimeters and altering gait pattern to an extent clinically obvious. The July 2021 examiner noted that such level of severity was not supported in the record, or by history or examination. In addition, the July 2021 examiner explained that joint disease does not "spread" to another joint or cause damage to another joint. As such, the Veteran's prepatellar tendon bursitis of left knee and the right knee strain were less likely than not related to the lumbar spine disability with degenerative joint disease. No baseline level of severity was established, and the examiner found no aggravation beyond its natural progression. The objective evidence does not support a finding of service incurrence. Barr, 21 Vet. App. at 307. The Board finds the July 2021 opinion probative; it is broad enough to reflect neither causation nor aggravation. In essence, no examiner has associated the Veteran's current bilateral knee disability, to include osteoarthritis, with service-connected disease or injury. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Bilateral Ankle Service treatment records show that the Veteran sprained his left ankle October 1974 and was given a limited profile for 14 days. There are no findings or complaints of right ankle problems or trauma. Clinical evaluation of lower extremities and feet were normal at his separation examination in January 1976. No bilateral ankle disability was documented. Arthritis of bilateral ankle was not demonstrated in active service or within the first post-service year. Post-service records, dated in November 2011, show complaints of bilateral ankle pain from one year ago, which gradually occurred. Pain was described as aching and localized over the ankle joints. Pain was worse with any weight-bearing and worse with activity. Examination in November 2011 revealed mild swelling in bilateral ankle with no erythema noted. There were full ranges of motion with no pain. Drawer test and talar tilt were negative. X-rays of ankles were unremarkable. The assessment in November 2011 was bilateral ankle pain most likely due to mild ankle osteoarthritis, versus inflammatory arthritis. Physical therapy was provided. An October 2013 VA examination report reveals a diagnosis of tenosynovitis of left ankle. The Veteran described the gradual onset of left ankle pain from five years ago. His ankle swelled after prolonged standing; pain was constant, and he could hardly walk two times a week. He denied flare ups. No right ankle disability was noted. Following examination in October 2013, the examiner opined that it was less likely than not that the Veteran's left ankle disability was incurred in or caused by active service. In support of the opinion, the examiner reasoned that the ankle sprain in October 1974 was transitory. There is no showing of chronic ankle pain during active service, and no records documenting chronic ankle pain after separation from active service. The examiner also noted that current ankle pain began five years ago. In September 2014, the Veteran complained of bilateral ankle pain; and described the pain as a Level 8 on a scale of 10. He had requested soft ankle braces. In April 2016, the Veteran reportedly stopped working due to pain in his knees and ankles. VA records, dated in September 2016, show an assessment of bilateral ankle pain, chronic, weight-bearing, ranges of motion, careful watch osteoarthritis; X-rays were planned. In this case, there is a gap of decades between the Veteran's separation from active service in 1976 and records documenting any bilateral ankle disability. The evidence reveals that the left ankle sprain during active service was acute and transitory; arthritis of either ankle did not manifest within one year after the Veteran's separation from active service in January 1976. As such, he is not entitled to direct or presumptive service connection. While the Veteran is competent to describe his symptoms, the evidence does not reveal any bilateral ankle disability at the Veteran's separation examination from active service. The Veteran specifically denied any arthritis, rheumatism, or bursitis; and denied any bone, joint, or other deformity in active service. Even assuming the Veteran was treated for recurrent ankle pain at times, there is no evidence of chronicity of care following active service. Here again, an alternative route to direct service connection for bilateral ankle disability, to include osteoarthritis, is not demonstrated. Walker, 708 F.3d at 1338-39. The Veteran also contends that his bilateral ankle disability is secondary to service-connected lumbar spine disability with degenerative joint disease. He still complained of bilateral ankle pain in November 2018; ankle braces were replaced. In December 2018, a physical therapist noted signs and symptoms of chronic low back pain and knee pain and ankle pain from degenerative disc disease, as noted with X-rays. The Veteran reported that his right ankle itched from a rash in February 2020; he applied medication. A July 2021 VA examination report reveals diagnoses of tenosynovitis of left ankle and degenerative arthritis of left ankle, and a diagnosis of right ankle sprain. The Veteran reported a medical history of straining his left ankle in active service, and that his right ankle "started getting bad;" the left ankle was worse than right ankle. The course since onset had progressively worsened, and current symptoms included burning, pain, swelling in left ankle, and stiffness. The Veteran reported no flare-ups. He did report bilateral ankle difficulty with climbing stairs, prolonged walking, and standing. X-rays in March 2016 had revealed remarkable soft tissue swelling of left ankle and mild degenerative arthritis. The Veteran recently retired as a traffic light technician and reported losing from zero-to-one week of work in the last 12 months due to bilateral ankle pain. Following examination in July 2021, the examiner opined that it was less likely than not that the Veteran's bilateral ankle disability was proximately due to or the result of the Veteran's service-connected lumbar spine disability with degenerative joint disease. In support of the opinion, the examiner reasoned that there was no clear evidence in the orthopedic literature to suggest an injury to one joint would have any significant impact on another or opposite uninjured joint or limbunless injury resulted in major muscle or nerve damage causing partial or complete paralysis, or shortening of injured limb resulting in leg length discrepancy of more than 5 centimeters and altering gait pattern to an extent clinically obvious. The July 2021 examiner noted that such level of severity was not supported in the record, or by history or examination. In addition, the July 2021 examiner explained that joint disease does not "spread" to another joint or cause damage to another joint. As such, the Veteran's tenosynovitis of left ankle, degenerative arthritis of left ankle, and right ankle sprain were less likely than not related to the lumbar spine disability with degenerative joint disease. No baseline level of severity was established, and the examiner found no aggravation beyond its natural progression. The objective evidence does not support a finding of service incurrence. Barr, 21 Vet. App. at 307. The Board finds the July 2021 opinion probative; it is broad enough to reflect neither causation nor aggravation. In essence, no examiner has associated the Veteran's current bilateral ankle disability, to include osteoarthritis, with service-connected disease or injury. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Left Eye Service treatment records show a finding of left eye exotropia in October 1973. In November 1974, the Veteran fell and hit his head; he felt dizzy for a few minutes and reported pain in left eye and abrasion. Examination revealed an abrasion to orbit of eye, which was tender and swollen. The assessment was mild cellulitis; medication was prescribed. During subsequent optometry examination, the Veteran reported blurriness in left eye; photophobia (light sensitivity), myopic astigmatism, and exotropia were noted. Sunglasses were prescribed. Refractive error of the eye is not considered a disease or injury for an award of VA compensation benefits. 38 C.F.R. § 3.303(c). Myopia and astigmatism are refractive errors. Likewise, the finding of exotropia is considered as analogous to a congenital or developmental defect. Congenital or developmental defects are not considered diseases or injuries within the meaning of applicable legislation governing the awards of compensation benefits. 38 C.F.R. § 3.303(c). Moreover, the presumption of soundness at entry to active service does not apply to congenital defects, because such defects are not diseases or injuries within the meaning of 38 U.S.C. §§ 1110 and 1111. See Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009). In this case, exotropia of left eye existed prior to the Veteran's 1974 fall and left eye injury; there is no showing that such superimposed injury resulted in additional eye disability. The evidence does not show that optic nerve disease manifested within one year after the Veteran's separation from active service. As such, he is not entitled to presumptive service connection. Diabetic tele-retinal imaging revealed no diabetic retinopathy in January 2015. VA records, dated in April 2015, showed complaints of some occasional dryness with contact lens use for which the Veteran required rewetting drops. His vision was stable (although poor in left eye for several years). His ocular history revealed that the Veteran did not start to wear eyeglasses until active service. His left eye always had been worse; exotropia started several years ago. Although referred for surgery, the Veteran was too nervous and never went. Impressions for both eyes were diabetes mellitus without retinopathy, mild cataracts, and high myopia. In April 2016, the Veteran felt that both his eyes were seeing less and complained of wearing contact lenses. He could not tolerate any light in his eyes. VA records, dated in July 2018, reveal that the Veteran was interested in muscle surgery to correct his eye deviation. Refractive error again was noted in both eyes in March 2019. Ocular examination in September 2020 revealed that the cataract in the Veteran's left eye was removed and a replacement intraocular lens was inserted. Diabetic retinopathy, without any decrease in visual acuity, was also noted in both eyes. The Veteran reported that poor vision had forced him to retire in 2012. Following examination in September 2020, the examiner explained that the Veteran fell in 1974, while serving in active duty as a cook. The Veteran reported that his left eye was scratched from the fall. Corneal abrasions typically heal within hours or days, and a scratched cornea will not cause a cataract. The Veteran's vision in each eye was 20/25, with no mention of scarring or cataract, at his separation examination in January 1976. Annual eye examination of both eyes in March 2021 revealed diabetes mellitus without retinopathy, hypertension without retinopathy, dry eye, and refractive error. Constant left exotrope was noted. In May 2021, the Veteran reported that he still had issues with his left eye even after undergoing surgery, which helped him "see a little bit better." Regarding left eye cataract, the Board recognizes the Court's decision in Romanowsky v. Shinseki, 26 Vet. App. 303 (2013), which held that a Veteran satisfies the current disability threshold when a disability exists at the time his claim was filed, even if the disability resolves prior to VA's adjudication of the claim. In a July 2021 addendum, the September 2020 examiner opined that the Veteran's left eye cataract and his diabetic retinopathy were less likely than not incurred in or caused by active service. The examiner reasoned that the Veteran had a corneal abrasion in service in 1974, and that corneal abrasions heal within days; a corneal abrasion will not lead to cataracts or retinopathy. Regarding conflicting medical evidence, the examiner explained that the Veteran did show a few peripheral dot hemorrhages in the periphery of each eye in September 2020, consistent with diabetic retinopathy. Clinically, however, these fine hemorrhages may come and go in the early stages of the disease, and may not have been present when examined by another practitioner. Here, the evidence is against finding that either left eye cataract or diabetic retinopathy of left eye is related to active service. No examiner has attributed the Veteran's left eye cataract or diabetic retinopathy to disease or injury in active service, to include the 1974 fall and left eye injury. Nor has the Veteran submitted evidence or information linking active service to the currently diagnosed left eye cataract or diabetic retinopathy. While he may fervently believe in such a connection, as a layperson the Veteran lacks the competence to render a nexus opinion on such a complex medical question. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). No medical professional has indicated even a possible link between current disabilities and active service. Moreover, service connection has not been established for the Veteran's diabetes mellitus. In this regard, secondary service connection is not warranted for diabetic retinopathy. The Board is within its province to decide as to whether the evidence supports a finding of service incurrence. See Barr, 21 Vet. App. at 307. Here, the first credible showing of pertinent disabilities is many years after service with no competent evidence that either left eye cataract or diabetic retinopathy is in any way related to active service. For the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for left eye cataract and for diabetic retinopathy of left eye. On these matters, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Bilateral Hearing Loss, and Tinnitus The Veteran contends that service connection for bilateral hearing loss and for tinnitus is warranted on the basis that he incurred a head injury as a result of a fall in active service, from which his hearing loss and associated tinnitus developed. Service treatment records show that he fell and hit his head in November 1974. He was not knocked out; he felt dizzy for a few minutes. He reported having pain in left eye and an abrasion. The examiner at the time noted an abrasion to orbit of eye, which was tender and swollen. The assessment was mild cellulitis, and medication was prescribed. A March 2020 VA examiner opined that service connection for bilateral hearing loss disability and for tinnitus was not warranted, taking note of no significant permanent shift in hearing thresholds beyond test variability from entrance to separation. The examiner noted no evidence of hearing loss at time of fall resulting in abrasion to orbit of eye; nor was there mention of hearing test or loss of hearing at the time. The Veteran's current hearing loss was consistent with normal aging hearing loss. Nor was tinnitus as likely as not caused by active service. Pursuant to the June 2021 Board remand, the Veteran underwent a VA examination in July 2021. The examiner opined that it was less likely than not that hearing loss and tinnitus were related to active service. The examiner reasoned that the Veteran's military occupational specialty of food services had a low profile for hearing loss. No mention was made of service treatment records noting dizziness and orbital cellulitis. A medical article of record regarding hearing loss as a possible complication of orbital cellulitis was not discussed. See www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo. Further, the Board directed that such service treatment records and medical article be considered and discussed in rendering any opinion. Remand to secure an adequate opinion is required. Left Eye Photophobia No VA examiner has addressed whether the Veteran's reports of longstanding photophobia are a chronic condition, a symptom of another disease, or whether it is at least as likely as not caused or aggravated by service. On remand, such must be addressed. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records for the period from November 2021 to the present. 2. Obtain an addendum opinion from the examiner who conducted the July 2021 VA hearing loss and tinnitus examination; the claims folder must be reviewed in conjunction with such. Physical examination is at the discretion of the reviewer. If the July 2021 examiner is not available, another equally qualified clinician may be consulted. The reviewer must opine as to whether currently diagnosed bilateral hearing loss and tinnitus at least as likely as not are caused or aggravated by service, to include the in-service head injury, complaints of dizziness, and assessment of cellulitis with tenderness and swelling under the left orbit in 1974. In so opining, the examiner is directed to address and consider the medical article of record discussing hearing loss as a possible complication of orbital cellulitis. A full and complete rationale for all opinions expressed is required. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Schedule the Veteran for a VA eye conditions examination. The claims folder must be reviewed in conjunction with the examination. The examiner must opine as to whether the Veteran's "photophobia" is a free-standing disability entity or condition, or is a symptom of another condition. The examiner must then opine as to whether photophobia, or any associated condition, is at least as likely as not caused or aggravated by military service. dizziness, and assessment of cellulitis with tenderness and swelling under the left orbit in 1974. A full and complete rationale is required for all opinions expressed. 3. Then, readjudicate the claims on appeal. If the benefits sought remain denied, issue a supplemental statement of the case and, after appropriate time for response, return the matters to the Board if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary C. Suffoletta 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.