Citation Nr: 21005542 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 16-25 866 DATE: February 1, 2021 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for left eye disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1957 to December 1960. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by a Department of Veterans Affairs Regional Office (RO). In July 2018, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The claim was remanded in October 2018 for further development. Entitlement to compensation under 38 U.S.C. § 1151 for left eye disability is remanded. In October 2018, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain a VA examination. The examiner was asked to provide the following opinions: (1) whether it was at least as likely as not that the Veteran had a left eye disability as a result of the medical care, or a lack thereof to include failure to timely diagnose or treatment, received at the VA medical center; (2) whether it was at least as likely as not that any additional left eye disability resulted of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part; and, (3) whether any additional left eye disability was a reasonably foreseeable outcome of the treatment received, including the left eye surgeries. The requested VA examination was obtained in November 2019. The examiner noted diagnoses for left eye neovascular glaucoma, bilateral pseudophakia, cystoid macular edema, blindness and complete visual field loss. With regard to the Veteran’s left eye cystoid macular edema, the examiner noted that the condition was secondary to a number of potential causes, but that the condition most commonly occurred within a few weeks following cataract surgery. In this regard, the examiner noted that the Veteran underwent left eye cataract surgery in 2012. The examiner further noted that the condition was also known to occur following retinal vein occlusion, and that the Veteran had been diagnosed with that condition at some point in time following the 2012 cataract surgery. With regard to the Veteran’s left eye neurovascular glaucoma, the examiner found that the Veteran’s total loss of vision was most likely due to this condition. In this regard, the examiner noted that the Veteran was diagnosed with early stage neovascular glaucoma in November 2012 which was attributed to having had an ocular ischemic syndrome as early as 9 days after his cataract surgery. The examiner noted that several attempts were made to address this condition including using extensive Pen Retinal Photocoagulation laser treatment beginning in December 2012. The examiner opined that it was “less likely than not (less than 50 percent probability)” that any additional left eye disability resulted of carelessness, negligence, lack of proper skill, error in judgement, or similar instance of fault on the part of VA. In support of this opinion the examiner noted the Veteran’s lay statements that VA medical efforts for his left eye had caused him to lose all vision out of that eye, specifically his 5 month wait period for cataract surgery. However, the examiner stated that having cataracts and delaying the removal of cataracts did not necessarily cause glaucoma, or the macular edema that he was found to have in August 2012. With regard to his glaucoma, the examiner noted that the condition was already an advanced case at that time. Specifically, the examiner pointed to a 2012 VA medical record that was 9 days post cataract surgery which noted left optic nerve head with glaucomatous damage from advanced open angle glaucoma, a condition for which the examiner noted the Veteran might have been living with for years, as well as suspicion of ocular ischemic syndrome and neo-vascularization at both the optic nerve head and a trace amount at the iris. Accordingly, the examiner concluded that a second more aggressive type of glaucoma had been upon the Veteran and was not due to any delay on the part of his medical care. Instead, the examiner noted that the advanced open angle glaucoma was a common type of vascular disorder in people over 55 with a history of hypertension and glaucoma. Additionally, the examiner noted that vascular accidents were common and unpredictable in those with hypertension. As such, the examiner concluded that shortly before or after the November 2012 cataract surgery, the Veteran’s left eye underwent an ocular ischemic event which “polished off the remaining vision in his left eye,” and that despite undergoing the Pan Retinal Photocoagulation procedure in December 2012 in an effort to save his vision, he had two types of glaucoma attacking his left eye. Therefore, the examiner found that the Veteran had not lost his vision due to any left eye surgical procedure. With regard to the questions posed by the Board’s Remand directives, the Board finds that the examination report adequately addresses the issues of whether the Veteran developed a left eye disability as a result of the medical care, or a lack thereof to include failure to timely diagnose or treatment received at the VA medical center, and whether any additional left eye disability resulted of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. However, the Board further finds that the examination report does not adequately address the question of whether the Veteran developed any additional left eye disability that was a reasonably foreseeable outcome of the treatment received, including due to the left eye surgeries. In this regard, the examiner noted two left eye conditions which he appears to relate to the November 2012 surgery; cystoid macular edema and ocular ischemic syndrome. With regard to the ocular ischemic syndrome, it appears that the examiner related the condition to the Veteran’s neurovascular glaucoma. However, the examiner further noted that the Veteran’s ocular ischemic syndrome was a common but unpredictable condition in people over 55 with a history of hypertension and glaucoma. With regard to the Veteran’s neurovascular glaucoma, the examiner noted that the condition may or may not have been present prior to the November 2012 surgery (“a condition for which the Veteran might have been living with for years”), but also noted that the Veteran was diagnosed with early stage neovascular glaucoma in November 2012 which was attributed to having had an ocular ischemic syndrome as early as 9 days after his cataract surgery. Therefore, it is unclear whether the Veteran’s early stage neovascular glaucoma occurred prior to his 2012 left eye surgery, or occurred as a result of his ocular ischemic syndrome. Therefore, the Board finds that the November 2019 VA examination report does not adequately address whether the Veteran’s cystoid macular edema, ocular ischemic syndrome and neovascular glaucoma was a reasonably foreseeable outcome of the treatment received; specifically, the 2012 left eye surgery. As such, the Board finds that a Remand is necessary to obtain an addendum opinion that addresses this question. The matter is REMANDED for the following action: Refer the Veteran’s claims file to the VA examiner who provided the November 2019 VA left eye examination. The examiner should provide the following opinion: Notwithstanding the acknowledgement of informed consent, based upon the specific facts and circumstances of this Veteran’s case, was any additional left eye disability, to include cystoid macular edema, neurovascular glaucoma and/or ocular ischemic syndrome, a reasonably foreseeable outcome of the treatment received, including the 2012 left eye surgery? Please explain why or why not. In particular, the examiner should note that with regard to the ocular ischemic syndrome, it appears that the examiner related the condition to the Veteran’s neurovascular glaucoma. However, the examiner further noted that the Veteran’s ocular ischemic syndrome was a common but unpredictable condition in people over 55 with a history of hypertension and glaucoma. With regard to the Veteran’s neurovascular glaucoma, the examiner noted that the condition may or may not have been present prior to the November 2012 surgery (“a condition for which the Veteran might have been living with for years”), but also noted that the Veteran was diagnosed with early stage neovascular glaucoma in November 2012 which was attributed to having had an ocular ischemic syndrome as early as 9 days after his cataract surgery. Therefore, it is unclear to the Board whether the Veteran’s early stage neovascular glaucoma occurred prior to his 2012 left eye surgery, or occurred as a result of his ocular ischemic syndrome. (Continued on the next page)   A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lamb, 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.