Citation Nr: 21076027 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 16-63 356 DATE: December 22, 2021 ORDER An initial rating in excess of 10 percent for right knee degenerative joint disease (DJD) is denied. An initial rating in excess of 10 percent for left knee DJD is denied. An initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Service connection for right eye vision loss is denied. Service connection for gastroesophageal reflux disease (GERD) is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Service connection for hypertension is remanded. FINDINGS OF FACT 1. The Veteran served on active duty from November 1965 to November 1969. 2. The preponderance of the evidence is against finding the Veteran's right knee disability was manifested by flexion limited to 30 degrees, extension limited to 15 degrees, ankylosis, lateral instability or recurrent subluxation, semilunar cartilage disability, or impairment of the tibia or fibula. 3. The preponderance of the evidence is against finding the Veteran's left knee disability was manifested by flexion limited to 30 degrees, extension limited to 15 degrees, ankylosis, lateral instability or recurrent subluxation, semilunar cartilage disability, or impairment of the tibia or fibula. 4. The preponderance of the evidence is against finding the severity, frequency, and duration of the Veteran's PTSD symptoms more closely approximated occupational and social impairment with deficiencies in most areas. 5. Right eye vision loss based on refractive error is not a disability for which service connection can be granted. 6. Right eye glaucoma was not shown in service and is not causally or etiologically related to service. 7. GERD was not shown in service and is not causally or etiologically related to service. 8. The Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee DJD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260-5003. 2. The criteria for a rating in excess of 10 percent for left knee DJD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260-5003. 3. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.7, 4.130, DC 9411. 4. The criteria for service connection for right eye vision loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS When the case was previously before the Board of Veterans' Appeals (Board) in September 2019, it was remanded for additional development. Increased Rating Turning to the relevant laws and regulations, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Ratings in excess of 10 percent for right and left knee DJD The Veteran's right and left knee DJD disabilities are each rated at 10 percent pursuant to DC 5260-5003. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. The Board will also consider all potentially relevant diagnostic codes. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). In order to warrant a higher or separate rating, the evidence must show: X-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations (20% under DC 5003); ankylosis of the knee with a favorable angle in full extension or in slight flexion between 0 and 10 degrees (30% under DC 5256); mild recurrent subluxation or lateral instability (10% under DC 5257); dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint (20% under DC 5258); symptomatic removal of semilunar cartilage (10% under DC 5259); flexion of the knee limited to 30 degrees (20% under DC 5260); extension of the knee limited to 15 degrees (20% under DC 5261); or impairment of the tibia or fibula with a mild knee disability (10% under DC 5262). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Turning to the evidence, the preponderance of the evidence does not support higher ratings based on limitation of flexion or extension. The Veteran is currently assigned a 10 percent rating for limitation of flexion with pain rather than measured limitation of flexion in the knees. To warrant a rating in excess of 10 percent for limitation of motion, the evidence must show flexion limited to 30 degrees or extension limited to 15 degrees. At no point during the appeal period was range of motion for either knee limited to flexion to 30 degrees or extension to 15 degrees. The September 2020 VA examination considered additional range of motion loss in degrees due to pain during flare-ups and repeated use over time. The examiner opined right knee flexion would be limited to 105 degrees and left knee flexion would be limited to 100 degrees. As such, the medical evidence does not support higher ratings under DCs 5260-5261 for limitation of motion. The Veteran has not claimed, nor does the medical evidence show, x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations due to degenerative arthritis; ankylosis; lateral instability or recurrent subluxation; semilunar cartilage disability; or impairment of the tibia or fibula to warrant a higher or separate rating for either knee. The Board notes, effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. DC 5256, DC 5258, DC 5259, DC 5260, and DC 5263 were unchanged under the amended rating criteria. DC 5257 and DC 5262 were amended. The Veteran has not claimed, nor does the medical evidence show, persistent or recurrent instability to warrant a separate or higher rating under the amended DC 5257 or medial tibial stress syndrome (MTSS), malunion, or nonunion to warrant a separate or higher rating under the amended DC 5262. The Board considered the Veteran's lay statements regarding his knee symptoms. The Veteran is competent to report knee symptoms. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (a lay person is competent to report observable symptomatology of an injury or illness). The Veteran is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's knee disabilities has been provided by the medical personnel who have examined him during the current appeal and directly address the criteria under which the disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusion, the Board affords these medical findings great probative value. The Board considered the Veteran's lay reports of functional loss, to include inability to sit, stand, walk for prolonged periods without experiencing pain, difficulty squatting, and difficulty with stairs. The Veteran's statements regarding physical restrictions pertain to functional limitations that are contemplated by the governing diagnostic code criteria and corresponding regulations. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011), DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. Difficulty performing a task, such as prolonged sitting, standing, walking, squatting, or stairs, is not a "symptom" set forth in any portion of the Rating Schedule, yet a result of the symptoms of pain, painful motion, and limitation of motion. In sum, the preponderance of the evidence is against the claim, entitlement to a higher rating for right knee disability or left knee disability is denied. A rating in excess of 50 percent for PTSD The Veteran's PTSD is rated at 50 percent pursuant to DC 9411. He contends a higher rating is warranted. All psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders ("General Rating Formula"). Under the General Rating Formula, a 50 percent rating is warranted under the General Rating Formula for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks occurring more than once a week, difficulty in understanding complex commands, impairment of short-term memory (i.e. retention of only highly learned material or forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted under the General Rating Formula for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as an unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and an inability to establish and maintain effective relationships. A 100 percent rating is warranted under the General Rating Formula for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including the ability to maintain minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that a veteran experiences symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Initially, the Veteran has been diagnosed with PTSD and depression. Because the August 2015 VA examiner opined that the depression is a progression of his PTSD, all symptoms will be discussed. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Turning to the medical evidence, a May 2011 VA examination reported sleep impairment, nightmares, violent behavior, increased irritability, temper outbursts, being fearful of new interactions, and actively avoiding interactions that might remind him of war-time conflicts. The severity of the symptoms was noted to be moderate and frequency of symptoms was noted to be constant. He reported his symptoms affect total daily functioning which results in isolation from others. He recently moved to a rural area to isolate himself from interpersonal contact. He indicated he no longer drove for fear of his own potential road rage response. He denied current suicidal ideation. He reported having three siblings, describing their relationship as distant, talking to them on occasion. He reported having two children, describing their relationship as satisfactory, they talk on the telephone on occasion. He was a widower. He reported prior to retiring in 2009, he worked in security-type positions. Since retiring, he indicated he chose to isolate himself from interaction from other persons. Mental status examination revealed full orientation, appropriate appearance, hygiene and behavior, and good eye contact. Affect and mood showed a flattened affect, mood swings, anxiety, and depressed mood. He became tearful during the interview and constantly looked over his shoulder toward the door. He reacted to every noise that was heard from outside the room. His agitation level increased throughout the interview. Communication, concentration, and speech were within normal limits. Panic attacks were absent. There were signs of suspiciousness, but not delusions. Hallucinations were noted to be present occasionally, including hearing indistinct murmuring that reminded him of voices. At the time of examination, there were no hallucinations observed. There was no evidence of obsessive compulsive behavior. Thought processes were appropriate. He was able to understand directions. There was no evidence of slowness of thought or confusion. Judgment and abstract thinking were normal. Memory was mildly impaired (forgets names, directions, recent events). There was no evidence of suicidal/homicidal ideation. The examiner described the Veteran's current psychiatric impairment as mild or transient psychiatric symptoms that cause occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. A November 2014 VA treatment record stated the Veteran's reported mood was "down/hopeless." His affect was dysphoric and anxious and he reported a sense of impending doom. On examination, he was neatly dressed. He reported last experiencing suicidal ideation about three days earlier without any plan or intent. He denied current suicidal/homicidal ideation, as well as audio/visual hallucinations. He was pleasant and cooperative, alert, and fully oriented. It was noted the Veteran was widowed. He stated dating, but it was too frustrating because it required him to remember holidays/birthdays/grandchildren's names. He indicated his relationship with his children was much improved since moving in with his daughter about three months prior. He reported contact with Facebook friends from VFW. He reported feelings of distrust that prevented him from socializing outside of the home. A May 2015 VA treatment record noted the Veteran reported he does not like to be around lots people and does not want to be touched. He reported nightmares about once a month. He had a flashback about 3 weeks prior, usually occurring twice a month. He reported enjoying spending time with his grandkids, but was unable to spend time with them for more than an hour. He indicated insomnia with difficulty in falling sleep, waking after 3 to 4 hours, but is usually able to fall back to sleep. He reported avoiding crowds, was startled by noise, and preferred to be left alone. He indicated he felt guilty about the war, blaming himself at times. He reported some situational rage, but was able to control it for his children. He admitted to some depression. He reported no current suicidal ideation because he loves his family and grandkids. He reported his energy level varies. He endorsed auditory hallucinations of "mumbling noise" without command. He endorsed sometimes having visual hallucinations of seeing people passing by him, which occurs about 3 to 4 times a month. He denied delusions, but endorsed paranoia about people. An August 2015 VA examination report noted predominately depressive symptoms. It was noted he lived with his daughter and son-in-law. He reported he last worked in 2011. He reported spending his day "away from everybody" or might go on a bike ride or take a ride. He reported watching old TV shows/westerns, plays games on the computer, and reads. He reported going to bed at 2 to 3am and would wake up at 11am. He reported he cannot be around people because they upset him. He described mild memory problems (some problems with dates/people's names/completing tasks he planned the night before). He reported having a problem with patience while living with his daughter and grandkids. He reported trying to stay away from people as much as possible. He reported depression since losing his wife and the relationship with a fiance ended 2 years prior. He alienated his kids in the past, but was building their relationships back up. The current symptoms noted were depressed mood, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, he was appropriately groomed. He was cooperative during the evaluation. His thought processes were logical and goal directed with no evidence of hallucinations or delusions. His speech was coherent with normal rate and volume. His mood was dysphoric and his affect was restricted. He denied current homicidal or suicidal ideation, plan, or intent. He was oriented to place and date. There was indication of poor concentration. His fund of general information and judgment was good. A May 2016 VA treatment record reported nightmares decreased to 1 to 2 times a week and he was able to sleep longer hours. He reported the auditory hallucinations got worse, describing hearing his name being called or noise more frequently and clearly. There were no command auditory hallucinations and no visual hallucinations, except shadows at times. He denied delusions or manic symptoms. He reported being depressed, but improved sleep, no feeling of hopeless, and no suicidal ideation. It was noted that he lived with his daughter and her family and endorsed good family support. A July 2017 VA treatment record indicated the Veteran was doing okay since the last visit. It was noted he still hears voices, it comes and goes, and he does not understand what the voice says. He indicated he was not bothered by the hallucinations. He reported having made a guitar from a cigar box, which was a hobby. He reported depression, but no suicidal ideation or feelings of hopelessness. He reported enjoying his grandkids. His sleep varies, with nightmares once every week or two. He indicated good family support. An October 2018 VA treatment record noted the Veteran was feeling very distressed because he just filed for divorce after getting married 6 months earlier. Mental status examination revealed the Veteran was casually dressed and groomed. His speech was fluent, spontaneous, and of normal rate and volume. His mood was depressed and his affect was dysphoric. Thought processes were coherent. There was no circumstantial or tangential thought. There was no evidence of delusions, suicidal ideation, homicidal ideation, or obsessions. He reported off and on auditory/visual hallucination. He was fully oriented. Insight and judgment were deemed fair. A June 2019 VA treatment record noted the Veteran was doing well. He did not feel depressed or worried. He reported being happy with his new long distance relationship of more than a year. He was planning a trip to see his significant other. He denied hallucinations, delusions, suicidal ideation and homicidal ideation. He reported some paranoia around lots of people. His appetite and sleep were noted to be fair. Mental status examination observed he was cooperative and displayed fair eye contact. He had slowed psychomotor movement. His speech was fluent, spontaneous, and of a normal rate and volume. His thought processes were coherent. There were no circumstantial/tangential thoughts and he did not show flight of ideas or loose association of thought content. There was no current evidence of delusions, suicidal/homicidal ideation, or obsession. He reported on/off auditory or visual hallucination. He was fully oriented and his memory was grossly intact. His insight and judgment were deemed fair. A December 2020 VA treatment record noted the Veteran was calm and pleasant. He reported that he was doing fair and not affected by the pandemic much, since he did not like to go out and was used to being at home. He continued to live with his daughter and her family, with good support. He reported being without major depressive episodes, no feeling of hopelessness, and no suicidal/homicidal ideation. He indicated he had not heard voices for the past 2 months and only felt slightly paranoid about people. He reported nightmares, but was able to adjust his emotions. He indicated that he was sleeping better. There were no current audio/visual hallucinations, delusions, or manic symptoms. A February 2021 VA treatment record reported no severe depression or anxiety symptoms, no frequent nightmares, no active hallucinations/delusion/manic symptoms, no suicidal or homicidal ideation. The Veteran was observed to be calm and pleasant. He was fully oriented. His speech was normal. His affect was appropriate and thought processes were coherent. His insight and judgment were deemed fair. Based on review of the evidence, the Board finds the Veteran's PTSD is appropriately rated at 50 percent throughout the period on appeal. The Board gives probative weight to the Veteran's lay statements during treatment visits and examinations describing the severity, frequency, and duration of his current PTSD symptoms. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Looking to the level of impairment contemplated under the criteria for a 70 percent rating, the Board does not find deficiencies in most areas such as work, family relations, judgment, or mood. Although the Veteran reported isolating and avoiding interpersonal activities, he reported living with his daughter and having a good relationship with her family. He reported some relationship with his siblings. During the appeal period, he got divorced, but also reported dating and having a significant other. He reported planning a trip to see his significant other. He reported contact with Facebook friends from VFW. He reported the hobby of making a guitar from a cigar box. He reported taking walks with his granddaughter and biking. Mental status examinations at treatment visits and examinations consistently observed the Veteran was fully oriented, speech was normal, thought processes were coherent, and insight and judgment were fair. Looking to the criteria for a 70 percent rating, the Veteran did not exhibit obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. The Board notes the Veteran endorsed suicidal ideation during a November 2014 treatment visit. Otherwise, the Veteran regularly denied thoughts, intent, or a plan involving self-harm in treatment records and during examinations. The Board finds the isolated report of suicidal ideation during the appeal period, in consideration with the severity, frequency, and duration of the Veteran's other PTSD symptoms, most closely approximated the symptoms contemplated by a 50 percent rating. The Board notes the Veteran's representative pointed to the symptoms of auditory hallucinations, nightmares, and paranoia as supporting a higher rating. See September 2021 brief. The Board finds the severity, frequency, and duration of these symptoms as reported by the Veteran, and the reported impact on his functioning, do not more closely approximate the symptoms contemplated by a 70 percent rating. Regarding hallucinations, the Veteran described hallucination frequency as occasional, on and off. He reported he was not bothered by the hallucinations. See July 2017 VA treatment visit. Most recently, December 2020 and February 2021 VA treatment visits denied hallucinations. Regarding nightmares, the Veteran reported nightmares about once a month in May 2015, nightmares 1 to 2 times a week with improved sleep in May 2016, nightmares once every week or two in July 2017, sleep noted to be fair in June 2019, nightmares but sleeping better in December 2020, and no frequent nightmares in February 2021. Regarding paranoia, the Veteran reported some paranoia at treatment visits, but regularly denied delusion. Overall, the Board finds the severity, frequency, and duration of these PTSD symptoms and resulting impairment do not more closely approximate the symptoms or functional impairment contemplated by a 70 percent rating. The Board recognizes the list of symptoms under the rating criteria are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Here, the Board finds the severity, frequency, and duration of the symptoms reported by the Veteran during the appeal period most closely represent the criteria for a 50 percent rating. The Board notes a prior representative pointed to a January 2014 "Mental Health Symptoms" form completed and signed by the Veteran to support a 100 percent rating for PTSD. See August 2019 brief. On the form, the Veteran "checked" the symptoms: anger, anxiety, chronic sleep problems, danger of hurting self or others, delusions, denial, depression, difficulty making decisions, emotional numbing, flashbacks, guilt, hallucinations, inability to make and keep friends, inappropriate behavior, intrusive thoughts, isolation, lack of emotions, lack of self-esteem, memory loss, neglect of personal hygiene, neglect of family, nervousness, no friends, panic attacks, periods of violence, problems with communication, problems at work, problems getting along with people, sense of helplessness, suicidal thoughts, suspiciousness, taking medication for mental conditions, and unable to share feelings. The only symptom boxes not checked were: drug abuse, heavy use of alcohol, overly concerned with personal hygiene, and substance abuse. The Board gives the January 2014 form low probative weight. The form is wholly inconsistent with the Veteran's statements at VA treatment visits, which as noted above, the Board gives probative weight. See Rucker, 10 Vet. App. 73. The Board finds the Veteran's statements made during treatment visits more credible than the January 2014 list of symptoms submitted for the purposes of a compensation claim. See Pond v. West, 12 Vet. App. 341, 345 (1999) (interest may affect the credibility of testimony). Treatment visit notes provide context for the time frame, severity, frequency, and duration of the symptoms reported. The January 2014 symptom list provided no context as to the time frame, severity, frequency, and duration of the symptoms listed. Accordingly, as the preponderance of the evidence is against the claim, entitlement to a rating in excess of 50 percent for PTSD is not warranted. Service Connection Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Loss of vision right eye The Veteran contends service connection is warranted for right eye vision loss. The record reflects a diagnosis of right eye refractive error and glaucoma. As such, the first element of service connection has been met. The November 1965 enlistment examination noted the Veteran had myopia. On examination, uncorrected bilateral vision was 20/200, corrected to 20/20. On the enlistment report of medical history, it was noted he endorsed eye trouble and wore glasses. An April 1966 periodic examination noted the Veteran had defective vision (20/200 bilaterally). The accompanying report of medical history noted he endorsed eye trouble and wore glasses. The November 1969 examination indicated he wore corrective lenses. Uncorrected vision was 20/400 in the right and 20/200 in the left. The accompanying report of medical history noted he endorsed eye trouble and it was noted he wore corrective lenses. A March 1970 examination report noted he had defective visual acuity; uncorrected vision was 20/400 bilaterally, corrected to 20/20 in the right eye and 20/25 in the left. At service separation, it was noted he had corrected vision to 20/20 bilaterally. VA treatment records from April 2002 and April 2003 noted evaluation of the eyes was normal. It was noted there was no pain, diplopia, photophobia, or discharge. An August 2009 VA treatment record stated the Veteran reported painless sudden loss of vision in the right eye one year prior. It was noted he did not see an eye doctor after the vision loss. A March 2012 VA treatment record noted a diagnosis of glaucoma and prescribed medication. A June 2013 VA treatment record noted complaint of blurry vision and diagnosis of refractive error. Another June 2013 VA treatment record indicated a diagnosis of glaucoma with loss of vision in the right eye. An October 2014 VA treatment record noted a complicated history of retinal detachment in his right eye with extensive retinal surgery in 2009. He was planning for retina surgery, but moved to Austin and continued follow-up care. He reported acute loss of vision around 2011 and was told by the VA eye clinic there was no intervention indicated. The Veteran subsequently lost vision in his right eye. It was noted that VA Austin records only reported severe glaucoma of the right eye. Based on the above, service connection for vision loss based on refractive error is denied because his reduced vision is correctable refractive error and is not a disability for the purposes of service connection. 38 C.F.R. §§ 3.303(c), 4.9. Refractive errors, such as myopia, hyperopia, and astigmatism, are considered developmental defects not eligible for service connection. Actual pathology, other than refractive error, is required to support impairment of visual acuity. Thus, service connection for vision loss based on refractive error is denied. With regard to loss of vision based on glaucoma, service connection is not warranted. In this regard, the STRs are silent for complaints or diagnoses of glaucoma. VA primary care visits from April 2002 and April 2003 noted evaluation of the eyes was normal, without eye pain, diplopia, photophobia, or discharge. The Board finds eye and vision symptoms are the type of symptom that would ordinarily be reported and recorded at a primary care visit. The earliest record of treatment for glaucoma is from 2012, with possible symptoms beginning in 2009, which is over 30 years after service discharge. Contemporary medical evidence is not required to show a disability or incurrence during service. However, the lack of treatment or corroborating medical evidence for many years may be considered as one of several factors in determining whether a disability was incurred during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). At an October 2014 VA eye care consultation, the Veteran reported acute loss of vision around 2011. The Board gives probative weight to this statement because it was made to a physician in effort to receive proper care. See Rucker, 10 Vet. App. 73. Finally, there is no competent evidence of record establishing a relationship between the Veteran's glaucoma and service. Accordingly, as the preponderance of the evidence is against the claim, service connection for right eye loss of vision is denied. GERD The Veteran contends service connection is warranted for GERD. A November 2018 VA treatment record reflected a diagnosis of GERD. Therefore, a current disorder has been shown. As to in-service incurrence, a review of the STRs reflect no complaints, findings, or diagnosis of GERD. As such, the medical evidence does not support the second element of direct service connection. An August 2013 VA examination report indicated the Veteran did not have a diagnosis of GERD. The examination report noted a history of reflux in 2008. He self-treated with over the counter reflux medications and was never medically evaluated. It was stated he currently had no reflux symptoms and was not taking any medications for this problem. VA treatment records do not reflect any diagnosis or treatment for GERD until GERD was noted as a diagnosis in November 2018. No treatment, symptoms, or etiology was discussed. The preponderance of the evidence is against finding service connection. There is no evidence of GERD in service. VA treatment records did not report symptoms of GERD, nor was a diagnosis of GERD noted, until November 2018, which was over 40 years after service separation. The Board finds GERD symptoms are the type of symptom that would ordinarily be reported during primary care or annual treatment visits. At the time of the 2018 diagnosis, no reference was made to the disorder being of long-standing duration. Without any competent evidence indicating his current GERD is etiologically related to service, the preponderance of the evidence weighs against the claim. Accordingly, as the preponderance of the evidence is against the claim, service connection for GERD is denied. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16. Substantially gainful employment is that employment that is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned, if the scheduler rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). The central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran is service connected for PTSD rated at 50 percent, diabetes mellitus rated at 20 percent, right knee DJD rated at 10 percent, left knee DJD rated at 10 percent, tinnitus rated at 10 percent, and hearing loss rated as noncompensable. His combined rating is 70 percent. Therefore, he meets the requirements for a TDIU on a schedular basis under 38 C.F.R. § 4.16(a). Even so, to grant TDIU it must be found that he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. In the May 2013 VA Form 21-8940, the Veteran indicated that he is unemployable due to his PTSD. He reported a high school education, and two years of college. He reportedly last worked in 2010 as an "intake worker" and previous long term employment doing security work. A November 2014 VA treatment record noted that the Veteran completed his GED while in service and attended community college, but did not finish. It was noted that he retired five years prior from a job in security after 25 years. The February 2021 VA knee examiner stated that the Veteran could be employed in a narrow range of light work framework. He can lift/carry 10 pounds frequently; he can lift/carry 20 pounds occasionally. He can stand/walk at least 2 hours in an 8-hour workday. He can sit about 6 hours in an 8-hour workday. He must periodically alternate sitting and standing to relieve pain or discomfort. He can push and/or pull an unlimited amount, other than as shown above for lift and/or carry. His postural limitations include frequently being able to climb ramp/stairs; occasionally being able to climb ladder/rope/scaffolds; occasionally being able to stoop, kneel, crouch, crawl; frequently being able to balance. He has no manipulative limitations, or communication limitations. Considering the Veteran's limited education, his longstanding history performing work only in security, his physical limitations due to his knee disabilities described above, and his inability to establish or maintain relationships other than with family members and other PTSD/depressive symptoms described above, the Board finds that he is not substantially and gainfully employable due to his service-connected disabilities. Notably, while no opinion is of record stating that he is unemployable due to service-connected disabilities, it is not clear that he has the physical capacity to perform physical labor or the education, training or skills which would translate into gainful sedentary employment. Therefore, entitlement to TDIU is granted. REASONS FOR REMAND Service connection for hypertension is remanded. The Veteran contends hypertension manifested during service or is related to service. The Veteran's representative contended there were multiple entries of pre-hypertension noted in service. See September 2019 representative brief. The representative stated, "According to the American Heart Association, a systolic pressure reading between 120-130 and/or a diastolic pressure reading between 80-89 indicates pre-hypertension readings. The Veteran's STRs show the following prehypertension readings while on active duty; 130/78 on 5/15/93, 140/100 on 3/11/95, 131/77 on 5/17/96, 122/80 on 8/21/96, 120/72 on 2/3/98, 142/80 on 11/24/98, 138/88 on 12/7/99, and 134/89 on 9/24/02, the last of which was just 6 months prior to discharge from active duty." The representative contended, according to a study published in the West Indian Medical Journal, found in the articles published by the National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, "prehypertension is associated with a three-fold increase in the incidence of hypertension." Additionally, the Veteran's representative contended the Veteran has confirmed service in Vietnam and is presumed to have been exposed to herbicide agents. The representative pointed to Veterans and Agent Orange: Update 11 (2018), which states there is now "sufficient" evidence of an association between hypertension and herbicide agent exposure. Id. The RO obtained a September 2020 VA medical opinion, which did not address the representative's contention regarding pre-hypertension readings during service or the contention that his hypertension is due to herbicide agent exposure. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension. The clinician should answer: Whether it is at least as likely as not (50 percent or greater probability) the Veteran's hypertension had its onset during service or is related to service, to include in-service herbicide agent exposure? In providing the requested opinion, the clinician should address: (a.) the October 1975 separation exam noting mild hypertension, (b.) the September 2019 representative brief contention that there were multiple entries of pre-hypertension noted in service and referenced medical literature, (c.) the September 2019 representative brief reference to the Veterans and Agent Orange: Update 11 (2018), which states there is now "sufficient evidence of an association" between hypertension and herbicide agent exposure. Tess Winkler Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Redman, 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.