Citation Nr: 21076239 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 11-22 591 DATE: December 22, 2021 ORDER Entitlement to service connection for residuals of a right ankle fracture is denied. Entitlement to service connection for hypertension is denied. Entitlement to an initial disability rating in excess of 10 percent for service-connected patellofemoral syndrome of the left knee is denied. Entitlement to an initial disability rating in excess of 10 percent for service-connected patellofemoral syndrome of the right knee is denied. REMANDED Entitlement to service connection for refractive error, bilateral eyes (claimed as blurred vision), is remanded. FINDINGS OF FACT 1. The Veteran's residuals of a right ankle fracture clearly and unmistakably pre-existed service and clearly and unmistakably did not undergo an increase in severity during active service. 2. The preponderance of the evidence of record is against finding that the Veteran has had hypertension at any time during or approximate to the pendency of the claim. 3. Throughout the period on appeal, the Veteran's service-connected left knee disability manifested no more than pain and stiffness with flexion limited to 135 degrees and extension limited to 0 degrees. 4. Throughout the period on appeal, the Veteran's service-connected right knee disability manifested no more than pain and stiffness with flexion limited to 135 degrees and extension limited to 0 degrees. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a right ankle fracture have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for an initial disability rating in excess of 10 percent for service-connected left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260. 4. The criteria for an initial disability rating in excess of 10 percent for service-connected right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2003 to January 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in August 2007 and November 2007 of a Department of Veterans Affairs (VA) Regional Office (RO). In an April 2018 decision, the Board denied the issues of entitlement to service connection for an eye disability and increased disability evaluations for right and left knee patellofemoral syndrome. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2020 Memorandum Decision, the Court set aside the April 2018 Board decision with respect to the claims denied therein and remanded them to the Board for further development and readjudication. This case was most recently before the Board in January 2021 when it was remanded for additional development. It has returned for adjudication. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (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 or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, such as arthritis and hypertension, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown if "the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage v. Gober, 10 Vet. App. 488, 498 (1997). 1. Entitlement to service connection for residuals of a right ankle fracture The Veteran claims that he is entitled to service connection for residuals of a right ankle fracture that occurred prior to service. Under ordinary circumstances for veterans of active military wartime service or peacetime service on or after January 1, 1947, for purposes of 38 U.S.C. §§ 1110, 1131, and 1137, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1132. The presumption of soundness may only be rebutted by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 C.F.R. § 3.304(b). This statutory provision is referred to as the "presumption of soundness." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). In VAOGCPREC 3-2003, VA's General Counsel reinforced that the presumption of soundness is rebutted only where clear and unmistakable evidence shows both that the condition existed prior to service and that it was not aggravated by service. The General Counsel concluded that 38 U.S.C. § 1111 requires VA to bear the burden of showing the absence of aggravation in order to rebut the presumption of sound condition. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48, 52-53 (2012); see also 38 C.F.R. § 3.304(b) ("Only such conditions as are recorded in examination reports are considered as noted."). This presumption is only rebutted where the evidence clearly and unmistakably shows that the Veteran's disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner, 370 F.3d at 1096; Bagby v. Derwinski, 1 Vet. App. 225 (1991). The two parts of this rebuttal standard are referred to as the "preexistence prong" and the "aggravation prong." Horn, 25 Vet. App. at 234. The aggravation prong may be met by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096; see also 38 U.S.C. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits, and, conversely, where the presumption is not rebutted, the Veteran's claim is one for service connection, and not aggravation. Wagner, 370 F.3d at 1096. Turning to the evidence of record, the Veteran's May 2002 entrance report of medical examination includes a note that the Veteran had a fractured right ankle with hardware retained in 1995. With an explicit finding of a right ankle disability on enlistment, the presumption of soundness does not attach, as the disability was noted at entrance to service. Therefore, the only benefit that can be awarded for a right ankle disability is service connection on the basis of aggravation of a preexisting right ankle disability. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). The remainder of the Veteran's service treatment records are absent of complaint or treatment for a right ankle disability. However, during a March 2007 VA general medical examination, about 2 months after discharge, the Veteran reported bilateral ankle stiffness. The examiner indicated that the Veteran had full range of motion without pain, swelling, instability, or flares of the right ankle. The examiner found the Veteran's ankles were normal to examination without crepitus or reduction of range of motion on repetition. During an August 2011 VA examination, the examiner noted that the Veteran had a scar on the right lower leg and ankle that was superficial with no underlying tissue damage. There was no inflammation, edema, keloid formation, or limited range of motion caused by the scar. The Veteran was afforded a VA examination in April 2021 to address the nature and etiology of his claimed right ankle disability. At that time, the examiner noted that the Veteran underwent a right ankle open reduction and internal fixation procedure with residual tenderness and range of motion loss. The Veteran reported injuring his ankle in 1995 while playing football. After the surgery, he was in a cast for 6 weeks. Since that time, the Veteran noted that the condition had improved. He denied current pain but stated that it will stiffen in cold weather. He denied instability and said the condition had no impact on his work. The Veteran denied flare-ups of ankle pain or any functional loss caused by the ankle disability. His range of motion was flexion to 40 degrees and extension to 15 degrees with both passive and active testing and the examiner described such as "abnormal or outside of normal range". However, the examiner found that the Veteran's right ankle range of motion did not contribute to a functional loss. There was no evidence of pain or crepitus on range of motion. The examiner stated that the Veteran experienced slight tenderness to palpation on the lateral side of the right leg. After a review of the claims file and the examination, the examiner opined that the Veteran's right ankle condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by service. The rationale was that there were no complaints of right ankle pain during service. In fact, an x-ray from May 2002 showed the hardware with no degeneration and a notation that there was "no impairment." The Veteran's post-service treatment records are absent of complaint or treatment for his right ankle. There is similarly no medical opinion stating that the pre-service right ankle injury was permanently aggravated beyond normal progression while in service. After a review of the above, the Board finds that the most probative evidence of record clearly and unmistakably shows that the Veteran's right ankle disability was not aggravated by his active duty service. Wagner, 370 F.3d at 1096; Horn, 25 Vet. App. at 234. There is no basis to allow the Veteran's claim for service connection for his preexisting right ankle disability. Consideration has been given to the Veteran's assertions that his right ankle disability was either aggravated by his active service or had its onset therein. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, aggravation of a musculoskeletal disability, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The severity and etiology of the Veteran's left ankle disability is not an assessment that is readily amenable to mere lay comment, as such involves the interpretation of diagnostic studies and clinical observations. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that the Veteran is competent to report his right ankle pain, there is no indication that he is competent to provide an opinion that the reported right ankle stiffness represents an aggravation of his pre-existing right ankle disability. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation for the above-cited right ankle disability. Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. As there is no competent medical evidence of record to support the claim for service connection for a right ankle disability, the preponderance of the evidence is against the claim, and the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The claim for service connection for a right ankle disability is denied. 2. Entitlement to service connection for hypertension The Veteran contends that he has hypertension which is related to his period of active service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of hypertension and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran's service treatment records are absent of complaint or treatment for hypertension. The Veteran's post-service treatment records indicate a medical history of hypertension. However, there is no evidence of treatment or medication prescribed for such, aside from an August 2021 notation that he would be given a blood pressure cuff for home monitoring. The Veteran was afforded a VA examination in March 2007. At that time, the Veteran reported that he had been told that his blood pressure was elevated frequently when he visited physicians. However, he denied ever being treated for hypertension and had no symptoms referable to hypertension. The examiner noted that the Veteran's pressures have always fallen to normal with repeated testing. The Veteran's blood pressure during the examination was 150/80 on both arms, sitting and supine. The examiner diagnosed "hypertensive reactor." The Veteran was afforded an additional VA examination in April 2021. At that time, the Veteran reported that he had been told that his blood pressure is a little high, but he was never diagnosed. He was told he is a reactor and has a positive family history. During the examination, his blood pressure was noted to be 136/97, 138/85, and 134/86. There were no pertinent physical findings, complications, conditions, signs, or symptoms related to hypertension. The examiner found no objective evidence on the examination to support any diagnosis of hypertension. After a review of the claims file and an examination, the examiner opined that the claimed condition was less likely than not incurred in or caused by service. The rationale was that a review of the medical records showed blood pressure readings during service ranging from systolic blood pressure between 134 and 144 and diastolic blood pressure between 83 and 86. The examiner noted one blood pressure reading after active duty in March 2007 of 150/80. No other blood pressure readings were found. The examiner stated that one isolated elevation does not make a diagnosis of hypertension. The examiner stated that the term "hypertension reactor" was assumed to mean "white coat hypertension," or a reaction to a stressful environment, rather than real hypertension. After a review of the above, the Board finds that while there are some elevated blood pressure readings in the Veteran's treatment records, a diagnosis of hypertension is not supported by clinical data. There is no indication that proper diagnostic testing was conducted to confirm the presence of hypertension. Instead, the statements of record appear to be based entirely on the Veteran's self-reported medical history, which is inconsistent with the findings shown on VA examination that do not support a diagnosis of hypertension. Consequently, the Board gives more probative weight to the VA examiners' findings. While the Veteran believes he has a current diagnosis of hypertension, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377, 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence. For these reasons and bases, the Board concludes that the most probative evidence fails to demonstrate that the Veteran has a current hypertension disability. Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Entitlement for service-connected disease or injury is specifically limited to cases where such incidents have resulted in a disability, and in absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board finds that the preponderance of the evidence is against the claim. Accordingly, the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-57. The claim for service connection for hypertension is thus denied. Increased Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to an initial disability rating in excess of 10 percent for service-connected patellofemoral syndrome of the left knee 4. Entitlement to an initial disability rating in excess of 10 percent for service-connected patellofemoral syndrome of the right knee The Veteran asserts that increased disability ratings are warranted for his service-connected left and right knee disabilities. The Veteran's left and right knee patellofemoral syndrome is currently awarded a 10 percent disability rating, each, under Diagnostic Code 5260. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Disabilities of the knee and leg are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263. VA's rating schedule provides for ratings of 10, 20, or 30 percent where there is limitation of flexion of the knee to 45, 30, or 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The rating schedule also provides ratings of 10, 20, 30, 40, and 50 percent for limitation of extension of the knee to 10, 15, 20, 30, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. For rating purposes, a normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Effective February 7, 2021, changes were made to the regulations pertaining to the knee. Specifically, Diagnostic Codes 5257 and 5262 were amended; the remaining diagnostic codes were left unchanged. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453, 76,462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5262). Based on the medical evidence before the Board, ankylosis, recurrent subluxation, lateral instability, impairment of the meniscus (semilunar cartilage), impairment of the tibia and fibula, and genu recurvatum have not been found or associated with the Veteran's knee disabilities and thus will not be considered here. Accordingly, the amended regulations will not be addressed. The Veteran was afforded a VA examination in March 2007. At that time, the Veteran reported that he injured his right knee about 8 or 9 months prior and that his symptoms recurred with jogging. The examiner noted that there was no swelling, and the joint was not unstable. He had full range of motion of the right knee and the knee was not weak and did not fatigue easily. The Veteran reported difficulty walking stairs because of the pain and acute flares with running. He did not wear a brace or use a cane. The Veteran reported that the left knee was stiff. However, there was no evidence of swelling, loss of motion, fatigability, or weakness. Range of motion testing of the knees revealed extension to 0 degrees and flexion to 135 degrees bilaterally with no swelling or crepitus and no change with repetitive testing. X-ray imaging of the knees was negative. The Veteran was diagnosed with bilateral patellofemoral syndrome. The Veteran was afforded an additional VA examination in August 2011. The Veteran reported stiffness and pain in the bilateral knees but denied weakness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation, and dislocation. He noted flare ups of knee pain occur 3 times per month and last for 1 hour. The Veteran stated that he had difficulty with standing and walking because it becomes painful after a while. His pain was relieved with ibuprofen. He had not experienced incapacitation in the previous 12 months due to his knee disabilities. In fact, he denied any overall functional impairment from the condition. The Veteran's walk was described as normal, but the examiner noted that the Veteran required braces on his knees for ambulation. Range of motion testing revealed extension to 0 degrees and flexion to 140 degrees bilaterally without loss of range of motion on repetition. There were no signs of abnormal movement or guarding of movement in either knee. There was also no evidence of crepitus or ankylosis bilaterally. Imaging of both knees was within normal limits. The examiner found that the knee disabilities would have no effect on the Veteran's occupation and daily activities. The Veteran was afforded a final VA examination in April 2021. The Veteran noted intermittent pain several times a week and stiffness in his knees. He denied swelling, locking, and giving way. The Veteran denied using braces or having specific treatment for his knee pain but took Aleve as needed. He stated that he no longer plays softball or goes on long hikes but that the disabilities have no effect on his occupation. The Veteran denied flare-ups of knee pain, a history of instability, and effusion of the knee. Range of motion testing was normal bilaterally, with flexion to 140 degrees and extension to 0 degrees in both knees with passive and active testing. There was no evidence of pain on range of motion or with weight-bearing. There was no evidence of crepitus or objective evidence of localized tenderness or pain on palpation of the joint of associated soft tissue. The Veteran was able to perform repetitive-use testing without additional loss of function or range of motion bilaterally. No other contributing factors of disability were indicated and there was no evidence of muscle atrophy, ankylosis, joint instability, or a tibial or fibular impairment on examination. The Veteran did not use assistive devises for ambulation. Considering the pertinent evidence in light of the governing legal authority, the Board finds the preponderance of the evidence is against the assignment of initial ratings in excess of 10 percent for either knee based on limited flexion pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260. As noted, the next higher rating contemplates flexion limited to 30 degrees. The record indicates that flexion was to at least 135 degrees throughout the objective medical testing of record. Similarly, the Veteran's extension is not shown to be limited to 10 degrees in either knee to warrant a separate compensable rating under Diagnostic Code 5261. The Board also finds insufficient evidence to support the Veteran's pain being so disabling as to limit knee motion actually or effectively to such an extent as to warrant the assignment of any higher rating for either knee under 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261. The Veteran could perform repetitive use testing during each examination with no additional limitation of his functional ability. The Veteran also repeatedly denied flare-ups except noting increased pain 3 times per month during the August 2011 VA examination that was relieved with over-the-counter medication. In short, while the records indicate that the Veteran clearly experiences pain and stiffness with resulting functional impairment bilaterally, it does not approximate the level of severity as described by the next higher rating under Diagnostic Code 5260 with flexion limited to 30 degrees or under Diagnostic Code 5261 with extension limited to 10 degrees. The Board thus finds that pain and functional loss has already been considered by the current ratings. For the foregoing reasons, the Board finds that the preponderance of the evidence is against any higher or separate disability ratings for the Veteran's bilateral knee disabilities. Accordingly, the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-57. The claims for increased initial disability ratings for the Veteran's service-connected left and right knee disabilities are denied. REASONS FOR REMAND 1. Entitlement to service connection for refractive error, bilateral eyes (claimed as blurred vision), is remanded. As noted above, this issue was denied by the Board and remanded by the Court to obtain an adequate medical opinion regarding the etiology of the Veteran's claimed blurred vision, to include identifying a cause and addressing the Veteran's contention that such was related to steroids prescribed to treat his service-connected pemphigus vulgaris (PV). The Board remanded this issue in January 2021 and an additional VA examination was obtained in April 2021. After a review of the claims file and an examination of the Veteran, the VA examiner essentially stated that there was no pathology to render a diagnosis. Accordingly, the examiner found that it was less likely than not that the Veteran's complaints of blurred vision were related to his complaints of blurred vision in service. Unfortunately, the Board finds that the opinion is incomplete and inadequate to adjudicate the claim. The Board notes that the U.S. Court of Appeals for the Federal Circuit held that symptomatology may constitute a disability for service connection purposes where the evidence shows the symptomatology causes functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). The Board further notes the Veteran has asserted his blurred vision is secondary to steroids used to treat his service-connected PV and the examiner did not address this contention. The matters are REMANDED for the following action: 1. Submit the Veteran's claims file to a medical professional qualified to provide an opinion regarding the nature and etiology of his blurred vision. If the examiner determines an additional examination is needed, one should be scheduled. All indicated tests and studies should be completed Following a review of the relevant records and lay statements, and an additional examination if indicated, the examiner should identify all diagnoses applicable to the Veteran's blurred vision. If the examiner determines there is no diagnosis, he or she should state whether the Veteran's blurred vision rises to the level of functional impairment of earning capacity. Then, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that: (a.) Any condition manifesting as blurred vision originated during or is otherwise etiologically related to the Veteran's active service. In providing his or her opinion, the examiner should address the service medical records showing in-service complaints of blurred vision, and the Veteran's statements that his blurred vision has persisted ever since service. (b.) Any condition manifesting as blurred vision is proximately due to steroids prescribed to treat the Veteran's service-connected pemphigus vulgaris. (c.) Any condition manifesting as blurred vision has been aggravated by steroids prescribed to treat the Veteran's pemphigus vulgaris The examiner must provide a rationale for all opinions offered. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Connor, 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.