Citation Nr: 21070369 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 18-31 162 DATE: November 23, 2021 REMANDED Entitlement to service connection for a bilateral eye disability, to include detached retinas, macular pucker, and/or retinitis, is remanded. Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include seizures, is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1974 to March 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a June 2021 Board hearing. A copy of the hearing transcript has been reviewed and associated with the claims file. The Board notes that, in October 2016, the RO denied service connection for a dental disability. The Veteran submitted a Notice of Disagreement (NOD) in March 2017, and the RO issued a Statement of the Case (SOC) in May 2018. However, the Veteran did not perfect an appeal for that issue by listing it on his June 2018 VA Form 9, Appeal to Board of Veterans' Appeals, or by submitting a separate Form 9 for the issue of service connection for a dental disability. Therefore, that issue is not currently before the Board. 1. Entitlement to service connection for a bilateral eye disability, to include detached retinas, macular pucker, and/or retinitis, is remanded. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA is obligated to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. Id. The Veteran has claimed entitlement to service connection for a bilateral eye disability. Specifically, he claims that his eye problems are caused by an in-service incident in 1974 or 1975, wherein a grenade blew up near his face during a training exercise. However, a review of his service treatment records does not show treatment for such an injury. In December 2015, the Veteran submitted a letter from R.A.K., M.D., F.A.C.S.. Dr. K. stated that he has treated the Veteran since October 1982 for eye problems. He indicated eye diagnoses of retinal tear, retinal detachment, nuclear sclerosis of the lens, and macular pucker. Dr. K. opined that the Veteran's eye problems are at least as likely as not related to the Veteran's 1974 grenade launcher incident. The Veteran has presented evidence of a current eye disability that may be related to his active duty service. Therefore, VA's duty to provide an examination has been triggered, and a remand is needed to obtain an examination. See id. In addition, the Veteran and his representative stated during his June 2021 Board hearing that they believe the Veteran's emergency room records, showing treatment for injuries related to the grenade explosion, were not forwarded to VA along with his service treatment records. Accordingly, these records, if available, should be obtained on remand. 2. Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include seizures, is remanded. The Veteran also asserts that he is entitled to service connection for residuals of a traumatic brain injury (TBI). In addition to the grenade explosion incident noted above, he stated that, while on active duty service, he was injured while trying to break up a fight when an object was thrown at his head. A review of the service treatment records does not show treatment for a head injury incurred during a brawl; however, a December 1977 record shows that the Veteran had sutures removed from his forehead, which had a horseshoe-shaped laceration. The Veteran testified during his Board hearing that he had a seizure about 25 years ago and has also experienced blackouts and blurred vision. Additionally, in May 1980 the Veteran wrote a letter informing VA that he dropped three educational units due to medical reasons, after he experienced a series of blackouts. The Veteran has submitted evidence that he may have a current disability related to a TBI incurred during active duty service. Therefore, the low threshold of McLendon has been met, and the Veteran is entitled to a VA examination. See 20 Vet. App. at 83. Additionally, as with the emergency room records showing treatment for injuries related to the grenade explosion, the Veteran and his representative stated that records showing treatment for the 1977 head injury, other than the note showing removal of sutures, were not forwarded along with his service treatment records. As such, these records, if available, should be obtained on remand. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file all of the Veteran's service treatment records, including any records from Fort Lewis and/or Coronado Island, showing treatment following a grenade explosion in 1974 or 1975 and any records showing treatment for a head injury in 1977. If such records are unavailable, this fact should be documented, and a formal finding of unavailability should be made. 2. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed eye disabilities. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. For each diagnosed eye disability, the examiner should opine as to whether the disability is at least as likely as not (a 50 percent or greater probability) related to the Veteran's active duty service, to include his claimed incident of a grenade exploding near his face. The examiner must provide a comprehensive rationale for each proffered opinion. If any diagnosis of record cannot be confirmed or validated, please explain why such diagnosis cannot be confirmed. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed traumatic brain injury (TBI) residuals, including seizures. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. For each diagnosed disability, the examiner should opine as to whether the disability is at least as likely as not (a 50 percent or greater probability) related to the Veteran's active duty service, to include his claimed incidents of a grenade exploding near his face and of an object being thrown at his forehead while breaking up a fight. It should be noted that the STRs reflect removal of sutures from the forehead in 1977. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.