Citation Nr: 21069462 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 20-27 772 DATE: November 18, 2021 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for left eye blindness is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1963 to January 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Board remanded the claim for further development. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 1. Entitlement to compensation under 38 U.S.C. § 1151 for left eye blindness is remanded. While the Board regrets further delay, additional development is necessary prior to adjudicating this appeal. The Veteran contends medical treatment at the VA Medical Center (VAMC) in Dallas caused his current left eye blindness. The Veteran asserts in July 2014, he went to the Dallas VAMC for treatment, for four to five days in a row. He reported that on the last day of treatment, he went home and was told not to take the patch off until that Saturday. He stated that when the patch was taken off, he was blind. See December 2016 VA Form 21-0820. The Veteran also asserted that sometime in 2014, Dallas VAMC treated his left eye with a laser. He stated the laser caused his blindness. Id. In the September 2020 remand, the Board requested an opinion on whether the Veteran has any additional left eye disability that was caused by a '2014 cataract extraction and lens replacement surgery.' Upon closer look, however, the record shows the Veteran underwent cataract extraction and lens replacement surgery at an outside (non-VA) hospital in 2013. A May 2013 VA ophthalmology record shows the Veteran had cataract extraction (CE) and intraocular lenses (IOL) at an outside hospital in January 2013. It noted there was no complication for the left eye; there was right eye cystoid macular edema (CME) which was being followed by Texas Eye Institute and Texas Retina. The left eye vision acuity was 20/40. The record also shows he had a selective laser trabeculoplasty (SLT) for the left eye on December 18, 2013 at the Dallas VAMC, not in 2014. The reason for the SLT was high pressure in the eye with glaucoma. Follow-up VA clinical notes dated in December 2013 reflect there were no left eye complications from the SLT. The Veteran was to return to the clinic in 4-6 weeks. VA records between December 2013 and August 2014 do not reveal any ophthalmology visits for his left eye. VA records are silent for left eye treatment until August 2014, at which time he reported significant vision loss in the left eye. An August 2014 VA ophthalmology record noted the Veteran presented for primary open angle glaucoma follow-up. It noted the Veteran lost to follow up for several months, and that he was supposed to be seen in 4-6 weeks, purportedly from his last visit in December 2013. The Veteran reported severe left eye vision loss 1 week ago. He stated he woke up with poor vision. He reported he was out of medication for about 1 month. The left eye vision acuity was "HM @ [hand motion at] face." A September 2014 VA ophthalmology record shows the Veteran presented for Avastin injection in the left eye. The note mentioned there was neovascular glaucoma (NVG) in the left eye; visual acuity of the left eye was light perception (LP). An October 2014 VA ophthalmology record indicates that the Veteran's visual acuity went from 20/30 to 'NLP' sometime between December 2013 and August 2014. Unfortunately, the medical opinions of record are not adequate for adjudication. The most recent June 2021 VA addendum opinion did not discuss the December 2013 left eye SLT or the VA treatments in 2014. The examiner opined that the Veteran's left eye blindness was not caused by his 2014 cataract extraction and intraocular lens implant surgery in the left eye. As noted above, however, the Veteran underwent left eye SLT in December 2013 and returned to VA in August 2014 with significantly deteriorated vision. He underwent further evaluation and treatment in September 2014. An addendum opinion must be obtained. The September 2020 Board remand directed the RO to obtain private medical records from Attempts to obtain medical records from Texas Eye Institute and Texas Retina. RO efforts to obtain records from Texas Retina, and from the Ophthalmology Surgery Center of Dallas, after receiving authorization from the Veteran were unsuccessful. The RO provided a VA Form 21-4142 to the Veteran in November 2020; he did not provide authorization for the Texas Eye Institute. As the appeal is being remanded for another matter, the Veteran will have another opportunity to provide the necessary authorization form for this facility. The matter is REMANDED for the following action: 1. Ask the Veteran to complete and return VA Form 21-4142 for Texas Eye Institute. Make two attempts to obtain relevant records from this facility unless it is clear after the first request that a second request would be futile. 2. Obtain an addendum medical opinion. The claims file and copy of the Remand which contains relevant information, must be made available to the examiner. The addendum opinion should include discussion of the Veteran's documented medical history and contentions. After a thorough review of the claims file, the examiner should answer the following questions: (a) Whether it is at least as likely as not that the Veteran has any additional left eye disability that was caused by the cataract extraction (CE) and intraocular lenses (IOL) at an outside hospital in January 2013; or the December 2013 left eye SLT at the Dallas VAMC; or, by any VA treatment in 2014, to include the September 2014 injection of Avastin. (Continued on the next page) (b) If so, then for each identified additional left eye disability, the examiner should state whether the additional disability was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. A complete rationale must be provided for the opinions requested. The VA examiner should again address the significance, if any, of the August 1, 2014 Dallas VAMC post-operative ophthalmology treatment record. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, 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.