Citation Nr: 21069428 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 14-30 178 DATE: November 18, 2021 REMANDED Entitlement to service connection for a bilateral eye disability to include mild blepharitis, status post (s/p) corneal refractive surgery (Lasik) and dry eye syndrome, to include as due to environmental hazards in Southwest Asia is remanded. REASONS FOR REMAND The Veteran served in the United States Army Reserves with periods of active duty service from December 1994 to April 1995; February 2003 to June 2003; December 2003 to February 2005; September 2007 to October 2008; and February 2011 to November 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, March 2021, and September 2021, the Board remanded the Veteran's claim for additional development. The Board regrets the delay associated with this remand, especially considering that this matter was the subject of three previous remands. However, another remand is necessary to ensure that the Veteran is afforded full compliance with the statutory duty to assist. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Entitlement to service connection for a bilateral eye disability, to include as due to environmental hazards in Southwest Asia is remanded. The Veteran contends that his bilateral eye disability is related to active duty service to include as due to exposure to environmental hazards in Southeast Asia. During the pendency of the appeal the Veteran has been variously diagnosed with mild blepharitis, mild posterior blepharitis, s/p corneal refractive surgery, bilaterally, and dry eye syndrome which has been related to his January 2002 refractive surgery. See July 2013, September 2014, and January 2020 VA examinations. In support of this claim, the Veteran has been afforded VA examinations in July 2013, September 2014, and January 2020. In addition, VA addendum opinions were obtained in March 2021 and September 2021. In September 2018, the Veteran's representative asserted that if surgery was not the cause, the Veteran's exposure to burn pits and the Gulf environment may have aggravated or caused this condition. The July 2013, September 2014, and January 2020 VA examinations have been previously determined by the Board to be inadequate for decision making purposes. Specifically, the September 2014 VA examiner opined the Veteran's mild blepharitis is a diagnosable condition, with clear and specific etiologic factors, the Veteran was not diagnosed with blepharitis while in service and his mild blepharitis is therefore not secondary to refractive surgery or to any specific exposure event/environmental hazards experienced by him during his service in southwest Asia. However, the examiner did not provide a rationale for her conclusion thereby rendering her opinion inadequate. On January 2020 examination the VA examiner noted, on eye examination today no diagnosis of mild blepharitis was made. The examiner diagnosed mild dry eye syndrome which she opined is related or due to Lasik surgery performed on both eyes in 2002. The examiner opined that because the Veteran had previously been diagnosed with blepharitis, and since it was recorded to be mild, and since no complaints related to blepharitis were presented on examination today, it seems to be resolved, and therefore, it is unlikely that mild blepharitis has been incurred due to dry eye during service. However, the examiner did not provide an opinion as to whether it is at least as likely as not the Veteran's blepharitis is related to his active military service, to include in-service exposure to environmental hazards, to include burn pits, during his service in Southwest Asia as directed in the September 2018 Board remand. In March 2021, the Board requested the RO obtain an addendum opinion that addresses whether it is at least as likely as not the Veteran's blepharitis is related to his active military service, to include in-service exposure to environmental hazards, to include burn pits, during his service in Southwest Asia. The Board noted that an opinion should be provided even if the Veteran does not currently have blepharitis because his blepharitis was diagnosed during the appeal period. In the March 2021 VA addendum opinion, the examiner opined blepharitis was less likely than not incurred in or caused by the in-service injury, event, or illness, including Southwest Asia service, Persian Gulf war, and presumed in-service exposure to burning pits. The VA examiner noted there is no evidence after Lasik surgery of eye complaints, blepharitis is a clear and specific condition and no evidence of complaints or diagnosis of blepharitis in service treatment records. She explained blepharitis is an inflammation of the eyelids, it affects the lid margin, is usually bilateral, is very common in aging persons, causes discomfort and irritation, can be caused by staphylococcal infection or seborrheic condition, and can cause disruption of the normal ocular surface function and reduction in tear film stability. In September 2021 the Board determined that it was still unclear whether the Veteran's blepharitis and dry eye syndrome could have been caused or otherwise etiologically related to environmental factors in Southwest Asia because the March 2021 VA examiner did not adequately explain why the Veteran's blepharitis, in this particular case, is less likely than not related to environmental factors in Southwest Asia. Specifically, the VA examiner did not address the Veteran's report of exposure to sandstorms, burning pits, and hot climates during his deployment. Additionally, the Board determined that the VA examiner did not adequately address why the Veteran's dry eye syndrome diagnosed on January 2020 VA examination could not be etiologically related to his service. On remand the Board requested the RO to obtain an addendum medical opinion from the same examiner who provided the March 2021 medical opinion, or another suitable qualified examiner. The Board directed the examiner to clarify the diagnosis for any bilateral eye disabilities proximate to or during the pendency of the claim and opine whether any diagnosed bilateral eye condition to include blepharitis and dry eye syndrome had its onset during service or is otherwise causally or etiologically related to his active duty service, to include his service in Southwest Asia. The Board noted the examiner must consider the Veteran's diagnoses for mild blepharitis and dry eye syndrome. The Board further noted that the examiner must consider and address the Veteran's reported exposure to smoke from oil fires, burning trash or feces, burning pits, solvents, paints, tent heater smoke and other fuels, vehicle or truck fuels, industrial pollutions, sandstorms, and hot climate. In the September 2021 VA addendum opinion, the VA examiner opined the Veteran's mild blepharitis is not secondary to any specific exposure event/environmental hazards experienced by him during his service in Southwest Asia. She reasoned service treatment records were silent for blepharitis condition, no evidence of blepharitis was present on examination in 2013, the Veteran ended his active duty tour in 2011 but the condition was not diagnosed until 2014, and the condition is not environmental but caused mostly by staph bacteria. The Board finds this opinion does not cure the deficiencies from the previous opinion. In providing the opinion that the Veteran's eye disability was less likely than not related to service, to include as due to exposure to environmental hazards in Southwest Asia, the examiner did not consider and discuss the Veteran's lay statements regarding the environmental conditions he experienced in Kuwait. The examiner also failed to address why the Veteran's dry eye syndrome diagnosed on January 2020 VA examination could not be etiologically related to his service. As the directives of the September 2021 remand were not substantially complied with, remand for a supplemental medical opinion is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that RO compliance with remand directives is not discretionary or optional and that the Board errs as a matter of law when it fails to ensure remand compliance). Furthermore, the VA examiner's opinion appears to be based upon a factually inaccurate diagnosis date, as the examiner noted the Veteran was not diagnosed with blepharitis until 2014. However, a review of the record reflects the Veteran was provided a diagnosis of mild blepharitis on July 2013 VA examination. The matters are REMANDED for the following action: 1. Arrange for an appropriate health care provider to review the Veteran's claims file and provide an addendum opinion as to all current bilateral eye disabilities and any bilateral eye disabilities diagnosed during the pendency of the claim. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. 2. After examination of the Veteran and a review of the claims file, the examiner should do the following: (a.) Identify all bilateral eye disabilities found in the record or on examination. The examiner's attention is directed to the Veteran's diagnoses of mild blepharitis, mild posterior blepharitis, s/p corneal refractive surgery, bilaterally, and dry eye syndrome. See July 2013, September 2014, and January 2020 VA examinations. (b.) For each bilateral eye disability identified or diagnosed on examination, the examiner should opine as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that the identified bilateral eye disability had its clinical onset in service or is otherwise related to active duty, to include as due to exposure to environmental hazards in Southwest Asia and explain why or why not. The examiner is advised that the Veteran is competent to report his symptoms and history, to include reports of exposure to environmental hazards in Southwest Asia, and such reports must be specifically acknowledged and considered in formulating any opinions. See October 2005 post-deployment health assessment. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Upon completion of the above, the AOJ should review the examiner's report to ensure substantial compliance with the Board's directives. Stegall, supra. 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Aston, 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.