Citation Nr: 21075029 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 17-01 580 DATE: December 17, 2021 REMANDED 1. Service connection for back disorder. 2. Service connection for a left eye disorder. 3. Service connection for a right eye disorder. REASONS FOR REMAND The Veteran served on active duty from October 1979 to October 1983. This case is on appeal from a May 2014 rating decision. In July 2021, the Veteran testified at a Board hearing. The record was held open for 90 days for additional evidence. No additional evidence was submitted. 1. Service connection for a back disorder. The Veteran contends that he has a back disorder from an in-service injury. In August 2017, the Veteran's representative submitted Social Security Administration (SSA) letter of disability indicating that the Veteran is disabled. During the July 2021 Board hearing, the Veteran's representative reported that the Veteran was injured in service during a truck engine explosion in which he was "blown" from the front portion of a truck, damaging the back and sustaining burns to the face. The Veteran reported that he was serving in Germany when he was trying to assist with the repair of a truck and was thrown back as a result of the shock wave of an engine explosion. Furthermore, he reported being rendered unconscious and waking up in a hospital. He also reported that while he does not recall what hospital in Germany he was treated in, he received follow-up medical treatment at the base medical facilities. The representative reported that the Veteran complained about back pain during service and after. Furthermore, the representative reported that the veteran "self-treated, self-medicated his back condition until it worsened beyond self-care." The Veteran reported that after service, he was employed in the construction industry as a supervisor until 1999 and stopped due to back problems. Also, he reported undergoing a SSA medical evaluation for disability, resulting in a 100 percent disability rating grant effective 4 years ago. The Veteran's service personnel records (SPRs) show that he served as a wire system installer and earned an overseas service ribbon. The Veteran's service treatment records (STRs) show that he reported and was treated for lower back pain and arm, ear, and finger injuries. In May 1979, the Veteran reported experiencing recurrent back pain and "stiffness." An October 1979 record show a history of low back stiffness noted. In February 1980, the Veteran reported back pain. The STRs also show that the Veteran was treated in Nellingen Health Clinic in Germany in 1983. During the Veteran's August 1983 separation examination, the back was marked normal but he reported "recurrent back pain." The Veteran's post-service VA treatment records show treatment for a back disorder. In this regard, the Veteran reported experiencing back lower back pain in July 2013. A May 2014 records shows that the Veteran reported worsening back pain from prolonged sitting, standing, walking, and bending. The treating physician found spinal mild degenerative change", and "small multilevel disc protrusions," and foraminal narrowing at L3/L4 and L4/L5. Also, an October 2014 record shows that the Veteran received "epidural steroid injection lumbar" treatment. Some February 2015 and November 2016 records show that the Veteran reported experiencing back pain and not being able to exercise after a chiropractor treated him. The Veteran was afforded a VA examination for the back claim in April 2014. During this examination, the Veteran reported experiencing back "pain on and off since" the truck engine explosion. Further, he reported experiencing "slight pain when he left the military but it really started to bother him about 5 years ago when he stopped working." The Veteran reported that while he was employed in construction, he was not performing much heavy lifting. He reported that his pain lasts a whole day, starting after sitting or standing for long periods of time. Moreover, he reported experiencing numbness in both legs "but more on the left" and flare ups every day that cause inability to bend or more, lasting 1-2 minutes. Also, he reported pain after. The Veteran denied pain in the legs and parasthesia in the legs. The examiner reviewed the claims file. The examiner opined that it is less likely than not that the Veteran has a back disorder that was incurred in or caused by an in-service injury, event, or illness. The examiner reported a diagnosis of "degenerative arthritis of the spine" from 2013. The examiner found small multilevel disc protrusions and foraminal narrowing at L3/L4, and L4/L5. The examiner noted decreased range of motion on repetitive motion and during flare ups due to pain and fatigue. The examiner concluded that while the Veteran claims that his pain was minimal at the time he was discharged "up until about 5 years ago," this is greater than 20 years since discharge that the Veteran's "pain started which is likely related to natural disease process." Also, the examiner noted that the Veteran was employed in construction up until a few years ago and injured his back doing heavy lifting. The Board finds that a remand is warranted for another VA examination to determine if the Veteran has a current back disorder related to service. Also, in the April 2014 VA examination and the July 2021 Board hearing, the Veteran reported that he was treated for in-service injuries to his back in a hospital in Germany and then a base medical facility. The Veteran should be afforded another opportunity to identify outstanding relevant treatment records. Furthermore, the Veteran reported that SSA medical examiners evaluated the back disorder for SSA compensation purposes. A remand is also warranted to allow VA to request these records. 2. Service connection for a left eye condition. 3. Service connection for a right eye condition. The Veteran also contends that he has a left and right eye disorder due to service. In the July 2021 Board hearing, the Veteran reported incurring bilateral eye damage by "fireball" to the face during the same incident that led to his back injury. He reported experiencing eye problems since then. Also, he reported experiencing vision problems since 1987 and eye dryness. Further, the Veteran reported experiencing worsening eyesight symptoms from 15 years ago. Moreover, he reported been diagnosed with glaucoma, hypertensive retinopathy, refractive error, sensitivity to light, and retinal macroneurysms. The Veteran's STRs do not include any reports of or treatment for a left or right eye disorder. His post-service VA treatment records show reports of eye pain in May 2015, left eyebrow laceration in March 2016, and treatment for glaucoma. Also, a November 2016 record noted a history of "macular microaneurysms" since 2007. In the July 2021 Board hearing the Veteran reported that he was treated for in-service injuries to his eyes in Germany. The Board finds that the Veteran should be afforded another opportunity to identify outstanding relevant treatment records. Furthermore, the Veteran reported that SSA medical examiners evaluated the eye disorder for SSA compensation purposes. As noted previously, a remand is warranted to allow VA to request these records. Also, the Board finds that the Veteran has not yet been afforded a VA examination in regard to the bilateral eye disorder claim. The Board finds that the low threshold requirement has been met for a VA examination, and that a remand is required to address the nature and etiology of all current left eye disorders. See McLendon v. Nicholson, 20 Vet. App. 79, 81(2006). These claims are REMANDED for the following actions: 1. Afford the Veteran an opportunity to submit or identify any outstanding relevant treatment records. Obtain any identified records with the use of the Veteran's authorization as necessary. If such records are unavailable, the file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain the Veteran's complete STRs to include treatment in a hospital in Germany and follow-up base medical treatment for back and eye injuries resulting from a truck engine explosion in 1983. 3. Obtain the Veteran's federal records from the SSA. Document all requests for information as well as all responses in the claims file. 4. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service back and bilateral eye injuries related to the truck engine explosion in 1983. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 5. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate medical professional to determine the nature and etiology of the Veteran's lower back disorders. The entire claims file should be reviewed by the examiner. (a.) Identify all of the Veteran's low back disorders since 1983. (b.) State whether it is at least as likely as not that each disorder had its onset during service or is otherwise related to an in-service event, disease, or injury, to include a truck engine explosion in 1983. A rationale should be provided for opinions expressed. 6. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate medical professional to determine the nature and etiology of the Veteran's bilateral eye disorders. The entire claims file should be reviewed by the examiner. Thereafter, the examiner is asked to: (a.) Identify all of the Veteran's bilateral eye disorders since 1983. (b.) For each disorder, state whether it is at least as likely as not that each eye disorder had its onset during service or is otherwise related to service, to include the Veteran's report of a "fireball" to the face a truck engine explosion in 1983. A rationale should be provided for opinions expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nevarez-Myrick, Nancy 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.