Citation Nr: 21072632 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 13-29 930 DATE: December 3, 2021 ORDER Entitlement to left eye diabetic retinopathy associated with diabetes mellitus, type II is granted. REMANDED Entitlement to service connection for bilateral eye disability, to include right eye diabetic retinopathy, senile nuclear sclerosis, and vitreous floaters is remanded. FINDING OF FACT The Veteran's left eye diabetic retinopathy is proximately due to his service-connected diabetes mellitus, type II. CONCLUSION OF LAW The criteria for entitlement to left eye diabetic retinopathy associated with diabetes mellitus, type II have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the Army from October 1969 to December 1973 with service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims were recently remanded by the Board in May 2021 for adequate VA examinations. Unfortunately, the Board finds that the recently obtained VA examinations and accompanying opinions are inadequate and fail to sufficiently address the questions raised by the Board in the May 2021 remand. Thus, the Board finds that an additional remand is necessary to properly adjudicate the Veteran's claim. See Stegall v. West, 11 Vet. App. 268 (1998). Nevertheless, the Board finds that it may proceed with the adjudication of the claim of entitlement to service connection for left eye diabetic retinopathy without any prejudice to the Veteran given the favorable finding below. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). 1. Entitlement to left eye diabetic retinopathy associated with diabetes mellitus, type II The Veteran contends that he has bilateral eye disabilities that are attributable to his service-connected disabilities, to include diabetes mellitus, type II and hypertension. Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Here, the Veteran has been service-connected for diabetes mellitus, type II since January 26, 2010. Recent VA treatment records from a May 2021 eye consult reveal a diagnosis of mild diabetic retinopathy as evidenced by a temporal cyst in the macula of the left eye. The temporary cyst in the macula of the left eye was identified after a dilated fundus examination was completed. In August 2021, a VA addendum was completed for the examiner to reconcile the May 2021 VA treatment note regarding a diagnosis of mild diabetic retinopathy in the left eye with the examiner's previous finding that the Veteran does not have diabetic retinopathy. The examiner stated that that Veteran's August 2021 fundus examination did not show hemorrhages or exudates on the left eye which are signs of retinopathy. The examiner noted the macular cyst of the left eye but stated that she was unable to determine if it is evidence of diabetic retinopathy without further testing. After careful consideration, the Board finds that the evidence is in equipoise as to whether the Veteran has a diagnosis of left eye diabetic retinopathy that is proximately due to or the result of his service-connected diabetes mellitus, type II. Under the circumstances, where there is an approximate balance between the positive and negative evidence, the benefit of the doubt is given to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Accordingly, the Board concludes that entitlement to service connection for left eye diabetic retinopathy is warranted. REASONS FOR REMAND 2. Entitlement to service connection for bilateral eye disability, to include right eye diabetic retinopathy, senile nuclear sclerosis, and vitreous floaters is remanded. The Veteran contends that he has bilateral eye disabilities that are attributable to his active service, including exposure to Agent Orange while in Vietnam. Alternatively, he contends that his bilateral eye disabilities are secondary to his service-connected disabilities, to include diabetes mellitus, type II and hypertension. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the May 2021 Board remand, the Board found that the December 2020 and January 2021 VA examinations and opinions were inadequate as the examiner failed to support her conclusions with a complete rationale. Unfortunately, the Board finds that the August 2021 VA examination and August 2021 and September 2021 addendum opinions continue to be devoid of complete rationales to support the conclusions offered. Additionally, the VA examiner failed to offer any opinions as to whether the Veteran's diagnosed eye disabilities are related to his service-connected hypertension. Specifically, in the September 2021 addendum opinion, the examiner opined that herbicide exposure does not have an eye diagnosis associated to such exposure, as officially listed in literature. The Board finds that this opinion is inadequate, as it is conclusory, and not supported by any rationale. An addendum opinion is needed to determine whether the Veteran's bilateral eye disabilities are at least as likely as not related to herbicide exposure. An adequate rationale should accompany the opinion and should not be based on the fact that eye disabilities are not enumerated conditions under 38 C.F.R. § 3.309 (e). Furthermore, while the examiner found that the Veteran's bilateral disabilities are not proximately due to or the result of diabetes and provided an adequate rationale, she failed to provide any rationale as to whether the Veteran's eye disabilities have been aggravated beyond natural progression by his service-connected diabetes mellitus. Finally, the examiner failed to offer any opinions or supporting rationales as to whether the Veteran's bilateral eye disabilities are at least as likely as not proximately due to or aggravated beyond natural progression by his service-connected hypertension. Thus, the Board finds that an addendum medical opinion is needed to properly adjudicate the Veteran's claim. The matters are REMANDED for the following action: Obtain an addendum opinion from an ophthalmologist, other than the ophthalmologist who completed the August 2021 and September 2021 medical opinions, addressing the nature and etiology of the Veteran's eye disabilities, to include (1) bilateral pinguecula, (2) bilateral senile nuclear sclerosis, (3) vitreous floaters, (4) dry eye syndrome, and (5) bilateral retinal drusen. The entire claims file, to include a copy of this remand, should be made available to and reviewed by the clinician. (a) For each eye disability, the examiner must opine on whether it is at least as likely as not related to an in-service injury, event, or disease, to include herbicide exposure. The examiner is advised that a negative opinion cannot be based solely on the fact that the eye disabilities are not on the list of diseases that are presumptively associated with exposure to herbicide agents. (b) For each eye disability, the examiner must opine on whether it as at least as likely as not (1) proximately due to the service-connected hypertension, or (2) aggravated beyond natural progression by the service-connected hypertension. An adequate medical opinion on secondary service connection will include separate rationales for the conclusions reached on the causation and aggravation prongs of secondary service connection as these are independent concepts. (c) For each eye disability, the examiner must opine on whether it is at least as likely as not aggravated beyond natural progression by the service-connected diabetes mellitus, type II. The medical opinions obtained must include a complete rationale for the conclusions reached. Medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, 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.