Citation Nr: 21072764 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 12-15 331 DATE: December 6, 2021 ORDER Service connection for an eye or vision disorder, to include blurry vision, is denied. FINDING OF FACT A current eye or vision disorder, to include blurry vision, did not begin during service and was not otherwise incurred or aggravated as a result of an in-service injury or disease; and a congenital defect to include refractive error was not subject to a superimposed injury or disease during service to result in a current disability. CONCLUSION OF LAW The criteria for service connection for an eye or vision disorder, to include blurry vision, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1990 to June 1994. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before a Decision Review Officer (DRO), but he withdrew his prior request for a Board hearing in September 2019. In November 2019, the Board remanded this issue for a medical opinion. The case now returns for further review, and the appeal is ready for a decision. Although additional VA treatment records (CAPRI) and other documents were added to the claims file in July 2021, after the last supplemental statement of the case (SSOC) in November 2020, those records do not contain additional information concerning an eye disorder or etiology or are irrelevant to this claim. Thus, no waiver or initial review by the agency of original jurisdiction (AOJ) is needed. 1. Service connection for an eye or vision disorder, to include blurry vision The Veteran seeks service connection for an eye or vision disorder based on jet fuel splashed in his right eye during service. He asserts that his disability began in 1992, in that it worsened a preexisting condition for which he wore glasses prior to service. He describes blurry vision, a gradual decrease in visual acuity, dryness, and irritation, with treatment since 2005, and that he keeps getting increased prescriptions for glasses especially for the right eye. See, e.g., September 2015 DRO hearing, October 2020 VA examination. As noted below, the evidence reflects diagnoses of refractive error, for which the Veteran was prescribed glasses, in addition to multiple other eye disabilities. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if first diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. The three-element test for service connection requires: (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). Refractive error of the eye itself, which includes presbyopia, astigmatism, and hyperopia, is not eligible for service connection as a matter of law, as it is a congenital or developmental defect and is not considered a disease or injury that is eligible for VA compensation purposes. However, service connection may be granted for an additional disability if the defect of refractive error is subject to, or aggravated by, a superimposed disease or injury during service which results in the additional disability. 38 C.F.R. § 3.303(c); VAOPGCPREC 82-90 (July 18, 1990); Natali v. Principi, 375 F.3d 1375, 1380 (Fed. Cir. 2004). As noted in the prior remand, VA treats a congenital or developmental "disease" or "defect," such as a refractive error of the eye, differently. The term "disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. On the other hand, the term "defect" is defined as structural or inherent abnormalities or conditions that are more or less stationary in nature. Defects are static conditions that are incapable of improvement or deterioration, whereas diseases are capable of such progression. See O'Bryan v. McDonald, 771 F.3d 1376, 1380 (Fed. Cir. 2014); Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009); VAOPGCPREC 82-90 (July 1990). Thus, for any congenital or developmental eye "defect," such as refractive error, the question is whether the disorder was at least as likely as not subject to a superimposed disease or injury during service to result in additional disability. For any congenital or developmental eye "disease," the presumption of soundness applies if the disorder was not noted on the Veteran's examination for entrance into service. However, the Veteran is not presumed sound for any noted disease, and the presumption of aggravation must be triggered for consideration. Different burdens of proof apply for each situation. See 38 C.F.R. §§ 3.304, 3.306; Quirin, supra. To be adequate, a medical opinion must be based on consideration of an appellant's prior history and examinations and describe the appellant's condition in sufficient detail so that the Board's evaluation of the claim may be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). An examiner must support the conclusions given with analysis, but the report must be read as a whole and need not "explicitly lay out the examiner's journey from facts to a conclusion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The examiner is not required to provide a detailed review of medical history or comment on every piece of favorable evidence in the record. Id.; see also Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that VA examiners do not have a reasons or bases requirement). Where the medical opinion is lacking in detail, "the Board is permitted to draw inferences based on the overall report so long as the inference does not result in a medical determination." Acevedo, 25 Vet. App. at 294. As discussed below, the October 2020 VA examination and opinion reports provided adequate information to adjudicate the claim, when read as a whole. The prior remand directives were at least substantially completed, particularly when taking into account that the Board now finds the Veteran was not presumed sound. In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A current disability is established based on several bilateral diagnoses, as noted below. An in-service injury of fuel splashed in the Veteran's eye is consistent with his duties as fuel specialist, as noted in his DD Form 214 and service treatment records. Although there is no specific documentation of any such injury, he is competent to make this report and is found credible as to having such an injury. The remaining element is a nexus to service, to include incurrence or aggravation. The Veteran is not competent to provide an opinion in this regard, to include whether he had any lasting effects such as an abrasion or visual change, from fuel in the eye. These questions require medical expertise and interpretation of his history and testing due to the complex nature of the involved neurological and optical systems. As discussed below, the evidence is against a nexus to service. Concerning a current disability, the Veteran filed his claim for service connection in December 2009. The medical evidence includes service treatment records, private records since 1995, VA treatment records since 2008, and November 2020 reports of an October 2020 VA examination with medical opinions for his claim. The October 2020 VA examiner summarized the Veteran's current eye or vision diagnoses of bilateral epithelial basement membrane dystrophy (EBMD), bilateral dry eye syndrome, bilateral Salzmann nodule, bilateral macular drusen, bilateral divergence insufficiency, and corneal scarring of the right eye that affected both eyes, therefore indicating actual bilateral corneal scarring. Although not noted in the examination portion of the report, an opinion report also stated that the Veteran has hyperopic astigmatism and presbyopia. These diagnoses are also reflected in the Veteran's post-service records, including scarring of the cornea in both eyes, plus bilateral cataracts. Hyperopic astigmatism (or hyperopia and astigmatism) and presbyopia are identified as refractive errors. See, e .g., VA optometry treatment records in July 2010, October 2013, and November 2019; private eye specialist treatment records in February 2011, May 2015, April 2017, and June 2018. Concerning the nature and timing of the Veteran's symptoms and diagnoses, the prior Board remand stated that the Veteran's service entrance examination found clinically normal eyes, with no "noted" defect or disorder. Therefore, the Board stated that Veteran was presumed sound upon entry into service for an eye disorder. However, upon further review, defective vision and the need for glasses were noted at service entrance; thus, he is not presumed sound for these conditions. Specifically, the Veteran's May 30, 1990, medical examination for enlistment noted clinically normal findings for the eyes in general, ophthalmoscopic evaluation, pupils, and ocular motility (items 24 through 27). However, testing showed bilateral distant vision of 20/100 that was corrected to 20/30, and bilateral near vision of 20/400 that was corrected to 20/40, as well as refraction findings noting lenses (items 59 through 61), and a notation that the Veteran failed depth perception with corrected vision (item 65). Although no eye or vision condition was listed in the summary of defects and diagnoses (item 74), the Veteran was assigned a physical profile of E-2 for abnormality of the eyes or vision (item 75). The Veteran then entered active duty on June 6, 1990. A June 11, 1990, record stated that the entrance physical had found no significant abnormalities except those listed below, including optometry. Visual acuity findings were again recorded, along with refractions and a prescription for spectacles (glasses), and a physical profile of E-2. On June 29, 1990, the Veteran returned to the optometry clinic to replace broken glasses, visual acuity findings were recorded, and the optometrist diagnosed hyperopia with right astigmatism. The plan was glasses with the noted prescription, and a routine exam in one to two years or as needed. These records are consistent with a congenital or preexisting eye defect of refractive error (hyperopia with right astigmatism) with resulting abnormal vision or visual acuity. For his claim and during the October 2020 VA examination, the Veteran has asserted that his blurry vision began in 1992 when he splashed gasoline in his eye. There are no other records of treatment or complaints for the eyes or vision during service, to include an injury in 1992 or a separation examination near June 1994. However, the post-service records directly contradict the Veteran's assertion of having blurry vision or any lasting eye effects, to include an abrasion, from any gasoline splashed during his eyes in 1992 or otherwise during service. Although the Veteran is competent to report noticeable symptoms, he is not credible in this regard, as the post-service contemporaneous treatment records are more probative. Specifically, a little more than one year after service, a July 1995 private eye evaluation noted that the Veteran's last evaluation was two years earlier during service. The Veteran reported in 1995 that no changes were noticed, and glasses were prescribed after testing. In July 1997, the Veteran again reported that he had noticed no changes since 1995, and glasses were prescribed. In September 1998, new frames were ordered because the prior ones were making his face break out. These records are not merely an absence of information; instead, the Veteran expressly or affirmatively reported that he had not noticed any changes, and objective examination and testing of the eyes found no abrasion or other changes. The Veteran's reports and the objective findings for treatment of his eyes have high probative value because they were made for the purpose of receiving adequate care. They were shortly after service and many years prior to his claim for benefits. Private records from 2007 forward and VA records from 2010 forward noted refractive errors of hyperopia, astigmatism, and presbyopia. Although a private record in February 2011 did not identify presbyopia, a July 2007 private record did list presbyopia, as well as the August 2011 VA record and subsequent VA and private records. See, e.g., private records in July 2007, February 2011, May 2015, April 2017, and June 2018; VA records in January 2010, July 2010, August 2011, October 2012, October and November 2013, October 2014, August 2015, November 2016, November 2017, November 2018, and November 2019. Other than the Veteran's refractive errors, the first complaint or treatment for eye or vision abnormalities was in private treatment records in 2003. A February 2003 record noted that the Veteran complained of a sudden decrease in visual acuity, with blurriness for near and distance vision with an onset about one month ago. Examination showed a slight distortion of the corneas and hypertrophic epithelium, among other findings. The impressions were dry eyes with hypertrophic epithelium and a corneal scar, with no history of inflammation, redness, photophobia, discharge, or trauma. The condition was treated conservatively with eye drops. An April 2003 record noted a followup for a corneal scar and dry eyes with hypertrophic epithelium. The Veteran had been using artificial tears every two hours most of the time, but his eyes did not feel any different and his visual acuity was unchanged. After examination and testing, which included a notation of subepithelial opacities as would be seen in anterior basement membrane (ABM) dystrophy, the impressions included ABM changes and possible Salzmann's nodules degenerative. The provider talked with the Veteran at length about visual acuity and the cornea, discussing possible laser epithelial debridement. A May 2003 record noted that the Veteran was there for followup for a corneal scar of the left eye (OS) and dry eyes with hypertrophic epithelium. He had tried lubrication and opacities persisted, so he was offered laser debridement (HDCL). Private records in July 2003 and August 2003 stated that the Veteran was following up for a corneal scar in the left eye (OS) with corneal debridement in the left eye, and he had been doing well with no pain. On July 22, 2003, he was "now" having a little irritation with a foreign body sensation, blurry visual acuity in the left eye, and photophobia. The provider stated that his cornea defect persisted without infiltrate. On July 24, 2003, the Veteran reported less photophobia and was doing well. On August 1, 2003, he had another followup and reported no changes. His vision was noted as 20/30 in the right eye and 20/40 in the left eye, and he was prescribed medication for two weeks. At a followup on August 26, 2003, the Veteran reported that his visual acuity was about the same. After examination, the impressions appear to note that the epithelium was intact but an irregular small stromal scar on the left eye persisted, ABMD was recurrent, there was no foreign body (FB) sensation, there was less keratitis with the lubricant prescription (or artificial tears), and a corneal scar persisted. He was also prescribed glasses. These records from 2003 are not merely an absence of reports or evidence. Instead, the Veteran expressly and affirmatively identified the onset or beginning of his noticeable symptoms of blurry or decreased vision as occurring one month earlier, or around January 2003. This was several years after service and approximately 10 years after his report of fuel splashing in his eyes in 1992. He did not mention any prior episodes of blurry vision or injury in service when he sought treatment. Additionally, this record expressly found abnormalities in the cornea noted as hypertrophic epithelium and a corneal scar, but no history of trauma (or injury), and followup records noted subepithelial opacities attributed to ABMD (which is later referenced as EBMD, as summarized below). The records noted blurry vision with a recurring erosion or recurrent ABMD after the left eye laser surgery with a left eye scar. Notably, these records focused on the left eye, whereas the Veteran has reported the fuel splash during service as occurring in the right eye. Several years later, a July 2007 private record noted that the last examination was in May 2006, and there was no change in prescription. The Veteran reported that his right eye cleared up last month with a prescription that he took for about two weeks. Examination showed spots on the right eye "as before," and he was advised to use lubricants. The assessment was hyperopia, astigmatism, and presbyopia. A September 2009 VA treatment noted that the Veteran reported no change in his vision, he wore thick glasses, and he needed new glasses. Then, a December 2009 record noted complaints of left eye pain, and the general provider saw no abnormality of the left eye or left eyelids and referred him to optometry. A December 2009 VA optometry consult for left eye pain noted reports of mild irritation that was worse when the eye was tired for the right eye, it "feels like scrape." The Veteran reported blurry vision in both eyes and stated that sometimes he would close one eye while reading. He denied redness, pain, discharge, photophobia, epiphora, or diplopia. The Veteran denied a history of retinal issues or problems, eye disease or surgery, but he reported having an abrasion of the cornea in the left eye around 2005. The VA provider assessed superficial punctate keratitis of the left eye, with no foreign body or foreign body tracking, and noted patchy superficial punctate keratitis in or near to the visual axis in the left eye. The Veteran was advised to use artificial tears and return in one year (December 2010) or sooner if he noticed a decrease in vision or increase in discomfort. In January 2010, the Veteran again sought VA treatment for noticing decreased near vision bilaterally, stating that he had to hold his reading material too close. He reported good distance vision bilaterally and that his ocular (eye) comfort had improved since beginning artificial tears. He reported a history of surgery to "scrape film off the cornea" of the left eye in 2005, and that he had poor vision in the left eye prior to this surgery and was unsure of the cause for the surgery. (This would refer to the 2003 surgery shown in his private records as summarized above, as there is no other suggestion or record of another surgery on the left eye.) This examination in 2010 showed subepithelial opacities of the cornea bilaterally, a large central opacity on the right eye and two small nasal opacities on the eye. The assessment was bilateral EBMD that was causing decreased vision in the right eye, and a questionable history of recurrent corneal erosion (RCE) and surgical corneal debridement of the left eye. (As noted above, the 2003 private records stated that subepithelial opacities of the cornea were consistent with ABMD, now called EBMD.) The VA provider also assessed macular drusen bilaterally and stated that this was likely congenital based on the Veteran's age. There was also hyperopia, astigmatism, and presbyopia. The Veteran was advised to use artificial tears, educated on the symptoms of recurrent corneal erosion, and told to return in 12 months or earlier if symptoms were noted. He was also fitted for new multifocal eyeglasses and advised to return as needed for adjustments. A July 2010 VA treatment record noted the Veteran's reports that artificial tears helped, his vision was stable, and he had mild floaters. Examination findings included for the cornea epithelium that there was right eye EBMD scarring temporally extending into the visual axis and left eye EBMD scarring nasally; and the macula had hard and soft drusen. The assessment was EBMD bilaterally that was stable from the previous examination and was causing decreased in visual acuity in the right eye greater than the left eye, macular drusen with some increase in number of drusen from the previous examination, and hyperopic astigmatism with mild presbyopia bilaterally. The plan was to return in 12 months for monitoring and continue use of artificial tears. An August 2011 VA treatment record noted stable vision with no changes noticed. The assessment was stage 2 non-exudative age-related macular degeneration left eye greater than right eye, and the Veteran was educated on macular degeneration and the importance of testing daily at home, including that any changes in retina could potentially lead to devastating vision loss. The provider explained the potential benefit of certain foods to prevent progression of macular degeneration, and recommended wearing lenses that protect from ultraviolet (UV) light while outside. The assessment also noted EBMD bilaterally, with no current epithelial defects, which was noted as a cause of decreased vision in the right eye greater than the left eye. The Veteran was advised to continue using artificial tears and return if he experienced ocular pain, photophobia, or a decrease in vision. The provider also assessed presbyopia, hyperopia, and astigmatism bilaterally; the management plan for this condition was "habitual spectacle prescription." During an October 2013 VA annual eye examination, the Veteran reported that he was having trouble seeing the TV and phone, and he felt that this may have gotten worse since the last examination, but it had always been a problem. The assessment noted that the Veteran's macular drusen were stable, with large drusen versus small pigment epithelial detachment (PED) noted on optical coherence tomography (OCT). For EBMD, right greater than left that contributed to reduced vision on the right, the Veteran was advised that even with a new spectacle prescription his vision would not improve due to changes on the front of his eye, and he should continue using artificial tears. The Veteran was given a new spectacle prescription for his hyperopia, astigmatism, and presbyopia, and he was fitted for new multifocal glasses. In November 2013, the Veteran complained of blurring at distance and near with his new spectacles, stating that he preferred his vision in his older pair of glasses; he was given new multifocal glasses. At his October 2014 VA annual eye evaluation, the Veteran reported that his vision was stable but slightly blurred in the morning upon awakening, and artificial tears helped sometimes. He also reported rare occurrences of diplopia, although he was unsure whether this occurred at distance or near vision, but it would come and go. The assessment was macular drusen bilaterally, noted as likely adult foveomacular vitelliform dystrophy with macular drusen bilaterally and a single vitelliform lesion of the left eye. The Veteran's age and condition appearance supported a diagnosis of macular dystrophy versus age-related macular degeneration (AMD). The condition was stable based on photo comparison, visual acuities were stable bilaterally, and OCT confirmed a stable vitelliform lesion nasally to the foveal avascular zone (FAZ) in the left eye. The assessment was EBMD right eye greater than left eye, which again was noted as potentially contributing to reduced vision in the right eye. This record first noted divergency insufficiency bilaterally and stated that the condition was very mildly symptomatic with intermittent diplopia. There was refractive error bilaterally, with a stable prescription and stable acuity. Subsequent VA optometry records continued to note bilateral macular drusen including left eye pigment epithelial detachment (PED), bilateral EBDM contributing to reduced visual acuity in the right eye, bilateral divergency insufficiency (with mild diplopia noted in 2014), and bilateral refractive error. See, e.g., VA treatment records in August 2015, October 2015, November 2016, November 2017, November 2019, and November 2019. An August 2015 record noted stable best corrected visual acuity (BCVA) related to macular drusen and EBMD. The Veteran reported wearing glasses fulltime, a longstanding blur, and double vision sometimes after long periods of reading and that closing one eye made it single vision. Although he denied any changes in vision, and the record noted stable best corrected visual acuity, a new spectacles prescription was issued. In October 2015, he reported computer vision difficulties and needing to make his screen bigger or move his head closer to see the font more clearly. He had not received his new glasses yet from the August 2015 evaluation. The macular drusen and left eye PED were noted as stable in 2015, 2016, 2017, 2018, and 2019. A November 2017 record stated that PED was first documented by OCT in 2013 but may have been present since 2010 based on fundus photos. For EBMD, the Veteran was status post corneal surgery in the left eye (which was in 2003 based on his private records), and the November 2017 record stated that the Veteran also had a superficial keratectomy in the right eye in February 2017. The November 2017 record noted EBMD that was non-central in the right eye and diffuse in the left eye, Salzmann nodules that were temporal to the line of sight in the right eye and nasal to the light of sight in the left eye, and scarring that was superior in the right eye nad nasal in the left eye upon examination of the corneas. A November 2018 record noted that the Veteran was no longer seeing his private eye specialist, Dr. L, since early 2018, who had been monitoring his EBMD. He denied painful episodes or any decrease in vision, and he stated that he was happy with his current correction and used artificial tears for dryness with adequate relief. The assessment noted no recurrent erosions for painful episodes for EBMD. A November 2019 record noted that the Veteran had a history of de-epithelization and superficial keratectomy in the left eye and a superficial keratectomy in the right eye, with no recurrent erosions or painful episodes. Examination of the corneas showed a right eye epithelial haze or scarring superior to the line of sight with trace EBMD, and left eye Salzmann's nodule temporal with trace EBMD. The November 2017 VA treatment record also first noted senile nuclear cataracts bilaterally. The provider stated that this condition had a possible mild visual significance, but it was likely that the Veteran's decreased best corrected visual acuity (BCVA) and glare were due to corneal abnormalities. A November 2018 record assessed mild senile cataracts with a slight contribution to decreased BCVA in addition to corneal irregularities. The provider educated the Veteran on natural age-related changes in the lens over time and the ability to affect vision. Similarly, a November 2019 record noted age-related nuclear cataracts bilaterally that were mildly contributing to the Veteran's BCVA in addition to corneal irregularities. For refractive error, a November 2018 treatment record noted that the Veteran's spectacles prescription was updated and he was educated on the importance of adjustments to ensure best optical clarity. In summary, the Veteran's VA and private treatment records since 1995 consistently show that his noticeable vision complaints, including ongoing blurry vision, began in 2003 or later, more than one year after his discharge from service in 1994. During the October 2020 VA examination, the Veteran reported current symptoms of dry and irritated eyes, mild blurring of vision, and decreased visual acuity. The Veteran used artificial tear drops and had prescription glasses or spectacles. Upon evaluation and testing, the VA examiner found abnormal corneas. For the right eye, there was a corneal scar in the stroma superiorly, immediate tear breakup time, and 1x1 mm Salzmann nodule temporally. For the left eye, there was immediate tear breakup time, and a 1x1 mm Salzmann nodule nasally. The examiner also found macula abnormalities of pigmentary dispersion in the macula bilaterally, including for the left eye drusen nasal to fovea. The examiner stated that the Veteran had bilateral epithelial basement membrane dystrophy (EBMD), and this had caused the development of Salzmann's nodules and dry eye syndrome. He had undergone a superficial keratectomy in each eye for his EBMD. The examiner further stated that the Veteran's dry and irritated eyes were symptoms of EBMD and dry eye syndrome, and they made it more difficult to read for long periods of time. The examiner stated that mild blurring of vision was related to Salzmann's nodules. The examiner further explained that the Veteran's Salzmann nodules and haze associated with them had caused the reduction of visual acuity in his right eye, and this reduced his ability to read small print. The Veteran's macular drusen, especially in the left eye, had also reduced his ability to read small print. There were no symptoms due to his corneal scars. The examiner further explained that the Veteran's decrease of visual acuity in the right eye was mainly caused by the Salzmann nodule and haze adjacent to it in the stroma. In the left eye, there was no central scarring or distortion, so the Veteran's blurred vision was caused by the large drusen rather than the Salzmann nodule. In other words, the examiner stated that the Veteran's decrease of vision in the left eye was due to the large drusen, as it is just nasal to the fovea. In contrast, the decrease of vision in the right eye appeared unrelated to his drusen, as there were no visible pigmentary changes centrally; they were all 1 disc diameter away from the fovea. This is generally consistent with the Board's independent review and notations by VA and private optometrists in multiple treatment records, as summarized above. The examiner opined that the Veteran's decrease in visual acuity or other visual impairment was not attributable to dry eye syndrome. The examiner explained that there was no superficial punctate keratitis associated with his dry eye syndrome, so while the Veteran's tear breakup time was poor, it did not appear to be affecting his central vision. This is generally consistent with the Board's independent review and summary above. Although a treatment record in 2009 noted superficial punctate keratitis in the left eye, this was temporary; and records generally attributed the Veteran's decreased visual acuity to his other eye conditions. The VA examiner stated that the Veteran's EMBD had an onset in 1992 based on the Veteran's reports of noticing blurry vision since 1992 related to gasoline splashing in his eye. However, as discussed above, this is inconsistent with objective medical records and the Veteran is not credible as to symptoms since that time. Instead, records show no diagnosis of ABMD (later noted as EBMD) or ongoing blurry vision until early 2003, which was bilateral but focused on the left eye for surgery. Indeed, the Veteran testified during his Regional Office hearing in 2015 that he had only temporary blurring of vision when fuel flashed in his eye on the flight line, and he flushed it out at that time. He stated that there was no immediate decline, but he gradually noticed worse vision primarily in his right eye. The examiner stated that the Veteran's Salzmann's nodules were first diagnosed in 2017 or 2018, and they appeared stable since that time. This is generally consistent with the Board's independent review of the evidence. As noted above, an April 2003 private record noted possible Salzmann's nodules, degenerative, but the first confirmed diagnosis of Salzmann's nodules was in 2017 and was found bilaterally. The examiner stated that the Veteran's macular drusen were first diagnosed in 2010 or 2013, and they appeared stable since that time. This is generally consistent with the Board's independent review and summary above, showing macular drusen since 2010 and that the condition and PED in the left eye were noted as stable. For divergence insufficiency, the VA examiner noted that the Veteran initially had intermittent double vision, but he no longer experienced double vision or diplopia. He stated that his vision felt better with one eye open. The examiner stated that the Veteran's divergence insufficiency would not cause a decrease in visual acuity but could cause visual discomfort, and it caused visual discomfort in this case. The examiner stated that divergence insufficiency was first diagnosed in 2014. This is generally consistent with the Board's independent review and summary above, noting divergency insufficiency since 2014, with intermittent diplopia or double vision reported in 2014 and noted as mildly symptomatic, but not subsequently. The VA examiner measured the Veteran's visual acuity for uncorrected distance vision as right eye 20/70 and left eye 20/200, both corrected to 20/40; and bilaterally uncorrected near vision as 20/100 corrected to 20/40. The examiner stated that the Veteran continued to have hyperopic astigmatism, and he had also developed presbyopia. This is generally consistent with the Board's independent review and summary of records, as above, and these are both refractive errors. Concerning a nexus, there is no competent evidence indicating that there may be a link between a current eye or vision disorder and an injury or disease in service. As noted above, the Veteran is not competent to offer an opinion in this regard. As discussed above, a VA examination was provided in October 2020, with opinion reports in November 2020. There are some inconsistencies in the various parts of the multiple opinion reports; however, the examination and opinion reports must be read as a whole. The examiner considered the lay and medical reports and addressed the reasonably raised theories of the current diagnoses, providing detailed rationale that applied medical expertise to the facts of this Veteran's case. Therefore, the VA examiner's opinions are adequate and highly probative. The examiner's opinions as to the nature and timing of the Veteran's eye or vision disorders and diagnoses, as well as the symptoms attributable to each current condition, are discussed above. Overall, all of the Veteran's symptoms and disorders other than refractive error began well after his service ended in 1994. The VA examiner also opined that the Veteran's current eye disorder, to include blurred visual acuity, was less likely than not (less than 50 percent probability) incurred in or caused by the in-service event of gasoline or jet fuel being splashed in the eyes. The examiner relied in part on literature as to potential damage caused by a splash of gasoline to the eye from the Centers for Disease Control (CDC). The examiner opined that the Veteran's hyperopic astigmatism existed prior to service and did not worsen during service or afterward, explaining that his prescription had remained stable over time, and his visual acuity had not worsened. The examiner noted that the May 1990 military entrance examination showed 20/30 vision in the right eye and left eye and hyperopic astigmatism was noted on refraction. The examiner stated that the Veteran had also developed presbyopia, which the examiner stated is a natural aging process and was not worsened by his service. This is generally consistent with the Board's independent review and summary of records, as noted above. There are repeated medical notations that the Veteran needed habitual or routine adjustments in his spectacle or glasses prescriptions for management of his refractive error of hyperopia, astigmatism, and presbyopia, even when he denied noticing any visual changes. A 2013 record also explained that the Veteran's vision complaints would not improve with a new spectacle or glasses prescription because he changes on the front of his eye. Thus, although the Veteran's uncorrected vision for near and distant vision may have changed over time, this was not attributed to any injury or disease in service. Treatment records focused on changes in his best corrected visual acuity or other findings to determine if his multiple diagnosed eye conditions had progressed. The VA examiner also stated that EBMD is genetic or congenital, and it would be classified as a disease for VA purposes, as it can progress or lead to the development of other conditions. The examiner stated that the Veteran's EBMD had caused the development of Salzmann's nodules and dry eye syndrome, and he had a superficial keratectomy in each eye for his EBMD, which also indicated that the condition was progressive and had worsened. The examiner stated that EBMD would not be caused by a gasoline splash to the eye, but it was unclear whether EBMD was exacerbated by service, because splashing gasoline fuel in the eye "could" cause an abrasion that "may not" heal properly in the presence of EBMD. In other words, the examiner stated that EMDB would have caused a higher propensity for an abrasion following a splash of gasoline in the eyes. However, the examiner then noted that there was no evidence of an abrasion from this incident in the claims file during service or otherwise, and medical records showed no decrease in visual acuity or visual field from the condition. As explained above, the examiner's notation that the Veteran's EBMD or blurry vision had an onset in 1992 is inaccurate and inconsistent with the other medical records. The Veteran's medical records less than five years after service, in 1995 and 1997, show no evidence of an abrasion or any other sign of EBMD (or ABMD), and the Veteran denied noticing any changes since his eye evaluation in service. His records in 2003 also did not find evidence of any prior trauma, injury, or abrasion; instead, they noted opacities or a "recurrent erosion" that associated with the disorder itself. An abrasion or related scar is something that would be expected to be found on an eye evaluation; thus, the absence of such a finding is negative evidence of there being no abrasion or lasting results from a fuel or gasoline splash in service. Therefore, the evidence does not show aggravation of EBMD in service. Although the VA examiner stated that EBMD could be subject to a superimposed illness, like Salzmann's nodules and dry eye syndrome, that is not what is meant under the VA standards for service connection. A superimposed illness or disease would be something during service, which is not the case here. Instead, Salzmann's nodules and dry eye syndrome were a progression of the EBMD itself after service. The VA examiner stated that the Veteran's macular drusen were less likely than not congenital and did not clearly exist prior to service. However, they would not be caused or affected by a fuel splash to the eye, as they are in the retina rather than on the front surface of the eye. In other words, macular drusen are subretinal and the splash of fuel should have affected only the anterior surface of the eye. As noted above, several post-service treatment records stated that the Veteran's macular abnormalities, including dystrophy or drusen, were likely age-related or congenital based on consideration of his age and eye condition at onset. They also identified dietary factors and UV light as potentially contributing factors. The VA examiner stated that divergence insufficiency is not congenital and did not clearly exist prior to service. However, this condition also would not be caused or impacted by a gasoline splash in the eye because it is a binocular vision (or double vision or diplopia) problem rather than a structural problem. There are also notations in the Veteran's VA and private records from optometrists or eye specialists that identify the likely etiology of his disorders, with no suggestion of any relationship to an in-service injury or disease. Instead, several of his disorders were medically noted as genetic, degenerative, or age-related. His ABMD or EBMD with opacities or corneal scars, Salzmann's nodules, dry eye syndrome, macular drusen, divergence insufficiency, and cataracts were not medically suggested as related to or progressions of refractive errors from service. There is no contrary medical opinion. The Veteran testified during his Regional Office hearing in 2015 that an optometrist had told him that scarring in eye was probably related to a chemical, and the only chemical he remembers getting in his eye was the gasoline or jet fuel during service. The Veteran is competent to report what he recalls his provider telling him; however, this recollection may not be accurate or may have been a misunderstanding based on his knowledge as a layperson. The Veteran's records in this case do not reflect any such statement by a VA or private optometrist or eye specialist. Instead, his records in 2003 and subsequently noted that he had scarring, opacities, or nodules in both eyes related to a disorder of the epithelial portion of the cornea diagnosed as ABMD or EBMD, including recurring erosions after left eye laser surgery, and progression to Salzmann's nodules. The Veteran's contrary reports are less probative, not credible, and outweighed by the objective medical notations and supporting documentation. In summary, the preponderance of the evidence is against service connection for any current eye or vision disorder under any reasonably raised theory. There is no reasonable doubt to be resolved in the Veteran's favor, and the appeal is denied. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wheatley 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.