Citation Nr: 21070743 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 15-20 134 DATE: November 24, 2021 ORDER Entitlement to service connection for ocular hypertension is granted. REMANDED Entitlement to service connection for retinopathy is remanded. Entitlement to Special Monthly Compensation (SMC) based on loss of use of sight is remanded. FINDING OF FACT The evidence is in equipoise as to whether the Veteran's ocular hypertension was caused by his service-connected hypertension. CONCLUSION OF LAW Affording the Veteran the benefit of the doubt, the criteria for service connection for ocular hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the U.S. Navy from December 1977 to March 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Board remanded the issues on appeal. The case has returned to the Board for further appellate review. Ocular Hypertension Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, may be service connected on an aggravation basis. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that his ocular hypertension is etiologically related to his service-connected hypertension. Affording him the benefit of the doubt, the Board finds that secondary service connection is warranted. The Veteran satisfies the first threshold element of secondary service connection, as he has been diagnosed with ocular hypertension. See July 2019 VA examination. Affording the Veteran the benefit of the doubt, the Board finds that he also satisfies the second threshold element of secondary service connection, that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310. First, the Veteran is service-connected for hypertension, and has been assigned a rating of 20 percent effective July 17, 2000. Second, there are two opposing medical opinions of record. During the July 2019 VA examination, the examiner opined that the Veteran's ocular hypertension was less likely than not proximately due to the Veteran's service-connected hypertension. In so finding, the examiner noted that there was a .21 millimeter (mm) Hg increase in intraocular pressure for a 10 mm Hg increase in systolic blood pressure, which was not large enough to cause ocular hypertension. In contrast, in a June 2021 opinion, M.S. (initials used to protect privacy), the Veteran's private physician, concluded that the Veteran's ocular hypertension directly resulted from his service-connected hypertension. M.S. cited to medical literature which noted that it was not merely the rise of blood pressure, but also fluctuations in blood pressure that affective ocular nerve death and dysfunction. Based on the above evidence, the Board determines that it is at least as likely as not that the Veteran's ocular hypertension was caused by or otherwise etiologically related to his service-connected hypertension. A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds that the June 2021 private opinion is highly probative on this issue. The examiner reviewed the claims file, to include the Veteran's medical history and found, based on the specific facts of the Veteran's case, coupled with objective medical principles, that his ocular hypertension was etiologically related to his service-connected hypertension. The opinion was based on sound medical rationale, and thus, is highly probative on the issue of etiology. The Board acknowledges the July 2019 negative VA opinion, but finds that it is less probative than the June 2021 private opinion. Notably, the June 2021 private examiner indicated that the medical literature cited by the July 2019 VA examiner supported a significant correlation between intraocular pressures and systolic and diastolic blood pressures. Thus, the Board finds the probative value of the July 2019 VA opinion is substantially outweighed by that of the June 2021 private opinion. Accordingly, affording the Veteran the benefit of the doubt, the Board finds the evidence is sufficient to establish that his ocular hypertension is etiologically related to his service-connected hypertension. REASONS FOR REMAND In the July 2019 VA examination, the examiner noted that the Veteran's mild hypertensive retinopathy resolved in April and August 2012, but that his hypertensive retinopathy in November 2008 and January 2009 was proximately due to his service-connected hypertension. In a subsequent September 2019 VA opinion, the VA examiner clarified that the Veteran does not have a current diagnosis of hypertensive retinopathy. However, in a May 2020 VA treatment record, the Veteran was noted to be legally blind. In addition, in a statement received in January 2020, the Veteran reported that his hypertension caused problems with his eyes, resulting in the need for cataract surgery in November 2019. He also explained that his physician wanted to perform a goniotomy for his glaucoma. Given the Veteran's worsening symptoms since the July 2019 VA examination, the Board finds that a remand is necessary to obtain a clarifying opinion regarding the Veteran's retinopathy. Finally, because a decision on the remanded issue of service connection for retinopathy could significantly impact a decision on the issue of entitlement to SMC for loss of sight, the issues are inextricably intertwined. Thus, a remand is required for the claim for entitlement to SMC. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion regarding the Veteran's retinopathy. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay assertations. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any diagnoses pertaining to the eye since the inception of the claim (i.e. since July 2012). Of importance, the examiner should reconcile any diagnoses noted with the diagnoses of record, to include retinopathy, cataracts, and glaucoma. If any previously diagnosed eye disorders, including retinopathy, are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For all eye disabilities diagnosed, the examiner should provide an opinion as to whether it is at least as least as likely as not that the disability manifested in service or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomology therein. The examiner should also provide an opinion as to whether it is at least as likely as not that any current eye disorder was either caused or aggravated by the Veteran's service-connected hypertension and ocular hypertension The examiner should address both the causation and aggravation questions in his or her rationale. "Aggravation" is defined as worsening beyond the natural progression of the disease.) (Continued on the next page) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. J. SAIKH Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jason Lyons, 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.