Citation Nr: 21076519 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 16-44 704 DATE: December 27, 2021 REMANDED Entitlement to service connection for a right eye disability is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Navy from January 1984 to January 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In August 2019, the Board denied the Veteran's service connection claims for a left knee disability, pseudofolliculitis barbae (claimed as razor bumps), and a right eye disability. The Veteran appealed this denial to the Court of Appeals for Veterans Claims (CAVC or the Court), which granted a Joint Motion for Partial Remand (JMPR) in August 2020. Consistent with the terms of the JMPR, the Board remanded the claim to the AOJ in January 2021 for VA examinations to assess the nature and etiology of the Veteran's claimed conditions, which were provided in April and July 2021. The Board finds that the opinion pertaining to the Veteran's right eye disability is inadequate, and while the Board regrets additional delay, remand is necessary to obtain a new VA examination. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the AOJ granted the Veteran's service connection claims for a left knee disability and pseudofolliculitis barbae (claimed as razor bumps) in an August 2021 rating decision. As this represents a full grant of the benefits sought, these issues are no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). 1. Entitlement to service connection for a right eye disability is remanded. In a January 2015 Notice of Disagreement, the Veteran reported that he has had problems with his right eye since injuring it during service in 2000. He further reported that this injury caused vision loss and that he now has to wear eyeglasses. Then, in August 2016, the Veteran reported that he has had problems with his right eye after injuring it during service in 1986, and that he continued to go to sick bay for years for the same problem until he retired. He elaborated that he has had blurred vision and pain in the right eye socket since the incident. He also reported that he can barely open his eyes when he goes outside. Meanwhile, the Veteran noted that he had no problems with his eye prior to the injury. In April 2021, the Veteran also indicated that he has experienced blurred vision, irritation, and light sensitivity in both eyes since injuring his right eye during service in 1986. At the May 1983 entrance examination, a medical examiner noted that the Veteran was nearsighted and required glasses. The Veteran's visual acuity was tested at this time. Although the findings are not entirely legibile, it appears as though his uncorrected visual acuity was 20/24.4 for distance vision and 20/20 for near vision. In addition to this evidence, service treatment records (STRs) shows that the Veteran was seen in September 1986 for complaints that a foreign body blew into his right eye. At this time, the Veteran's visual acuity was 20/25 in the right eye and -20/30 in the left eye, though it is unclear whether this reading is for distance or near vision. The eye was rinsed with two bottles of water and a fluorescent examination of the eye revealed no foreign body. However, it was noted that the Veteran's visual acuity remained the same. STRs also show that the Veteran was struck in the right eye while playing basketball in October 2000. At this time, he reported having watery discharge, photophobia, and redness immediately after the injury. Deep nasal and temporal scleral injection of the right eye was noted on examination and the Veteran was diagnosed with traumatic iritis of the right eye. The Veteran was prescribed drops Cyclogyl eye drops to dilate the eyes and was advised to use them twice daily for 48 hours. Subsequently, STRs demonstrate that the Veteran complained of continued symptoms from the trauma to his right eye. During an examination in August 2003, he complained that his vision has decreased in his right eye over time and that glasses poorly correct his vision in either eye. He also complained that his right eye sometimes ached, but he denied having any ongoing photophobia, redness, or other ocular complaints. On examination, his distance and near visual acuity with correction was 20/20 in both eyes and the examiner concluded that the Veteran shows no evidence of vision loss secondary to his past history of trauma to the right eye. Ultimately, the examiner concluded that the Veteran sustained a blunt injury leading to traumatic iritis acutely, but the condition completely resolved without any permanent visual sequalae. However, the Veteran complained again in October 2003 of occasional aching and watering of the right eye. At this time, the treating doctor noted that no abnormalities were observed with a hand lens and indicated that the recent ophthalmology examination was normal. In April 2021, the Veteran was provided a VA examination to evaluate the nature and etiology of his claimed right eye disability. The Veteran reported being struck in the right eye while working on a naval ship in 1986. He further reported that both eyes have become more blurred, irritated, and sensitive to sunlight since the incident. The examiner diagnosed the Veteran with photophobia in both eyes and concluded that this condition was less likely than not related to an in-service injury, event, or illness. In support of this conclusion, the examiner noted that he could not find any supporting evidence of an injury to the right eye during service. The examiner elaborated that STRs documented a collision during a softball game, but neither eye was damaged during this event. The examiner also indicated that the Veteran only mentioned problems in his left eye at the time of the VA examination. However, as noted, there is evidence in the STRs demonstrating that the Veteran sustained two injuries to the right eye during service and that he complained of blurred vision, irritation, and watering of the right eye in subsequent treating visits during service. Additionally, the Board notes that the Veteran's uncorrected visual acuity during the April 2021 VA examination was 20/40 for distance vision and 20/50 for near vision, which demonstrates a worsening in visual acuity since service. Because the VA examiner did not address this evidence, his opinion is inadequate. See Reonal v. Brown, 5 Vet. App. 548 (1993). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature, onset, and etiology of his right eye disability. Any and all studies, tests, and evaluations deemed necessary by the examiners should be performed. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. The Veteran is competent to attest to observable events and symptomatology and such reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. The examiners should address the following: (i) Identify all diagnoses associated with the Veteran's claimed right eye disability. (ii) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's right eye disability manifested during service or is otherwise etiologically related to service, to include symptoms of vision loss, blurred vision, light sensitivity, and irritation. * The examiner must address the Veteran's lay statements that he has experienced vision loss, blurred vision, light sensitivity, and irritation of the right eye since service, as well as the changes to the Veteran's visual acuity since service that are documented in the record. * The examiner must also address documentation in STRs of treatment for injury to the right eye in September 1986 and October 2000, as well as care for continued symptoms in August and October 2003. 3. After ensuring that the opinions comply with the terms of this remand, the AOJ should re-adjudicate the claim. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Beech, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.