Citation Nr: 21069849 Decision Date: 11/20/21 Archive Date: 11/20/21 DOCKET NO. 18-16 864 DATE: November 20, 2021 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for loss of left eye is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1962 to May 1966. This matter comes before the Board of Veterans' Appeals (Board) from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.902(c). 1. Entitlement to compensation under 38 U.S.C. § 1151 for loss of left eye is remanded. The Veteran contends that improper VA treatment ultimately resulted in the need to have his left eye removed. VA treatment records show the Veteran had left eye cataract surgery on July 13, 2010. In September 2010 he was seen with a complaint that it felt like he had a stitch in the left eye. In November 2010 he was noted to have pseudophakic bullous keratopathy in the left eye. He testified that the initial cataract surgery failed, and he underwent a second surgery which also failed. He then reports he underwent cornea transplant surgery that failed after surgical stitches were removed, and emergency cornea surgery to reattach was done twice. After that failed, he ultimately underwent surgery to remove the left eye in December 2015. The Board finds that a remand is required to obtain an opinion as to whether the need for left eye removal was due to carelessness or negligence on the part of VA surgical treatment or follow-up treatment, or whether the condition was the result of an event that was not reasonably foreseeable. VA records from March 30, 2015, May 12, 2015, July 17, 2015, September 1, 2015, and January 28, 2016 indicates that records from University Health had been scanned into VistA imaging. Additionally, VA treatment records reflect numerous ophthalmology appointments dating since 2010 where the reports were scanned into VistA imaging. On remand, these records should be obtained and associated with the claims file. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records and all VistA Imaging scanned records pertaining to ophthalmology visits, to include surgery and follow-up treatment, dating from 2010 to the present. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, forward the claims file to an ophthalmologist to obtain a medical opinion. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. After review of the claims file, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the VA surgical and follow-up treatment the Veteran received caused or contributed to the need for the left eye enucleation? (b.) If the treatment caused or contributed to the need for left eye enucleation, is it at least as likely as not that the proximate cause of such was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in providing treatment? (c.) If not, was the proximate cause of the need for the left eye enucleation due to an event not reasonably foreseeable (one that a reasonable health care provider would not have considered an ordinary risk of the treatment provided)? A complete rationale for all conclusions and opinions should be provided. 3. If the claim remains denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lance, 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.