Citation Nr: 21005587 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 19-06 072A DATE: February 2, 2021 ORDER Entitlement to service connection for left shoulder disability manifested by pain is granted. Entitlement to an initial rating higher than 70 percent for major depressive disorder (MDD) is denied. Entitlement to an effective date of May 4, 2016, for the award of a total disability rating due to individual unemployability (TDIU) is granted, subject to the laws and regulations controlling the award of monetary benefits. REMANDED Entitlement to service connection for dry eye syndrome is remanded. Entitlement to service connection for low back disability is remanded. Entitlement to service connection for right shoulder disability is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s left shoulder disability is related to an in-service injury, event or disease. 2. The Veteran’s MDD symptomatology does not more nearly approximate total occupational and social impairment at any time during the period on appeal. 3. From May 4, 2016, the evidence is at least evenly balanced as to whether the Veteran’s service connected MDD precluded him from securing or following a substantially gainful occupation and the Veteran’s claim for a higher initial rating for MDD was pending from that date. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for left shoulder disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for an initial 100 percent rating for MDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, diagnostic code (DC) 9434. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for an effective date of May 4, 2016, for entitlement to a TDIU, have been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.6, 4.7, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1964 to March 1968. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for MDD, evaluating it as 70 percent disabling, and denied service connection for lower back, left and right shoulder disabilities, and dry eye syndrome, and a May 2017 rating decision wherein the RO continued its previous denial of service connection for dry eye syndrome. In June 2017, the Veteran filed his notice of disagreement with the denial of service connection for dry eye syndrome, and in July 2017 filed his notice of disagreement with the 70 percent rating for MDD, and the denials of service connection for dry eye syndrome, left and right shoulder disabilities, and lower back disability. The Veteran was issued a statement of the case in January 2019, and in March 2019 perfected his appeal to the Board. In July 2020, the Veteran appeared at a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. The Board notes that the issues of entitlement to service connection for dementia, cervical spine disability, left elbow disability, and traumatic brain injury were raised by the Veteran and his attorney during the July 2020 Board hearing and July 2020 follow-up letter from the attorney. These issues, however, have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ); therefore, the Board does not have jurisdiction over the claims. The issues are referred to the RO for appropriate action, to include informing the Veteran and his attorney that a claim for benefits must be submitted on the application form prescribed by the Secretary of VA and providing such forms. See 38 C.F.R. § 3.150 (a) (providing for furnishing of appropriate application form upon request for VA benefits); 38 C.F.R. § 20.904 (b) (“The Board shall refer to the agency of original jurisdiction for appropriate consideration and handling in the first instance all claims reasonably raised by the record that have not been initially adjudicated by the agency of original jurisdiction”). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability proximately due to or the result of a service connected disease or injury. 38 C.F.R. § § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a non-service connected disability that is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § § 3.310 (b). Left Shoulder The Veteran testified that he injured his shoulder when he fell out of a truck while in service, and that he has suffered from shoulder pain since that time. The Veteran’s service treatment records do not reflect any complaints of, or treatment for a left shoulder disability, and his February 1968 medical examination report upon discharge does not note any left shoulder issues. In a July 2017 medical care questionnaire, the Veteran reported pain in his shoulders, and back among other places. In a July 2017 letter, the Veteran reported falling off the back of moving 5 ton vehicles, stating he felt pain immediately after each event, but that he ignored it. He stated that he currently suffers from shoulder, left elbow and lower back pain which has progressively worsened. For the following reasons, the Board finds that the evidence is at least evenly balanced as to whether entitlement to service connection for left shoulder disability is warranted. The Veteran testified that he currently suffers from left shoulder pain and his post-service medical care questionnaire indicates that he has pain in his left shoulder among other places. The Veteran is competent to report his observable symptoms of pain, and there is no indication in the evidence of record that he lacks credibility. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). In addition, the Veteran competently and credibly reported that he twice fell off of a truck during service in Korea. Thus, the Veteran’s lay statements regarding the cause of his pain satisfy the in-service injury requirements, and the dispositive issue is whether there is a nexus between the Veteran’s current left shoulder disability and his in-service injury. The Veteran has consistently and competently provided evidence that his left shoulder pain has persisted since his in-service injury. There is no indication that the Veteran’s statements lack credibility, thus they are afforded significant probative weight. See Buchanan v. Nicholson, 451 F. 3d 1331 at 1337 (Fed. Cir. 2006). (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). With regard to whether the current disability requirement has been met, the Federal Circuit held that pain alone can constitute disability if it causes impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). In this case, the evidence shows that the Veteran has left shoulder pain for which he takes over-the-counter medications, and that the pain makes it difficult for him to perform the physical tasks necessary for employment. He reported in his July 2017 statement that he could not share his symptoms with potential employers for fear that they would not hire him. Thus, the Veteran’s left shoulder pain due to his in-service injury has caused impairment such that the symptom would constitute disability, to include impairment of a similar severity, frequency and duration contemplated by the rating schedule. See also Wait v. Wilkie, __ Vet. App. __, No. 18-4349 (August 26, 2020) (indicating that the Board must make the factual determination as to whether manifestations rise to a level of functional impairment in earning capacity with consideration of the Rating Schedule, but the presence of a symptoms or manifestation in the Rating Schedule is not dispositive). Although the Board could remand the claim for a medical opinion, there is sufficient evidence to decide the claim, and a remand could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c). Moreover, to the extent that the grant of service connection in this case is based primarily on lay evidence, “nothing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself.” Buchanan, 451 F.3d at 1335. The evidence is thus at least evenly balanced as to whether the Veteran’s left shoulder disability is related to his in-service injury. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a left shoulder disability manifested by pain is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Ratings Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). Major Depressive Disorder The Veteran’s MDD is currently rated 70 percent disabling from May 4, 2016. The criteria for rating MDD are found at 38 C.F.R. § 4.130, DC 9434. MDD is rated under the General Rating Formula for Mental Disorders. Under this formula, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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 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 inability to establish and maintain effective relationships. A 100 percent evaluation requires 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 maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Symptoms listed in the VA’s general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words “such as” that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held “that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration.” Id. at 117. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. When evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran’s capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, not solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126 (b). The Veteran testified that he has had suicidal thoughts and an attempt, and had a restraining order filed against him by his wife and children as he had tried to kill his wife. His friend testified that the Veteran has suffered memory loss, and that his personal relationships have deteriorated because he has difficulty with his memory. The Veteran’s friend also reported that the Veteran’s MDD caused the Veteran to be totally impaired in social interaction and employment. A November 2016 disability benefits questionnaire (DBQ) reflected that the Veteran’s diagnosed MDD caused occupational and social impairment with reduced reliability and productivity. The DBQ indicated that the Veteran’s wife reported that the Veteran has poor sleep patterns, depression, and a desire to isolate. The Veteran denied suicidal or homicidal ideation, but he reported feeling tired and worn out, stating that depression has continued for most of his life. The Veteran’s MDD symptoms included depressed mood, near-continuous panic or depression, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in adapting to stressful circumstances including work or a work-like setting, and an inability to establish and maintain effective relationships. The psychologist noted that the Veteran’s thought processing was off-topic and tangential, and his insight and judgment impaired. October 2018 VA treatment records reflect that the Veteran reported thoughts of killing himself with carbon monoxide. He also reported spending the day mowing the yard and watching television. He stated that he spends time with friends, going out to have breakfast with them, and talks with them on the phone. He also stated that he attends church on Sunday. The Veteran reported a fair relationship with his wife, but stated that he does not feel close to her or the children. A November 2018 DBQ reflected that the Veteran’s MDD causes occupational and social impairment with deficiencies in most areas. The Veteran reported that he can no longer do yardwork, but still attends church. The Veteran reported hopelessness, and suicidal ideation. His other symptoms of MDD included depressed mood, anxiety, near-continuous panic or depression, chronic sleep impairment, impairment of short and long term memory, flattened affect, circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and suicidal ideation. The examining psychologist noted that the Veteran has difficulty maintaining concentration and focus on work over a period of time, has intrusive thoughts which interfere with the ability to stay focused on the task at hand, significant difficulty remembering instructions and details of work assignments, and is so depressed that he has difficulty sustaining energy and motivation to complete assignments at work. Based on a preponderance of the evidence, the Board finds that the Veteran’s MDD symptomatology does not more nearly approximate that which is contemplated by a 100 percent disability rating at any time during the appeal period. While the Veteran has reported trying to kill his wife and suicidal ideation, and his testimony indicated he suffered impairment in thought process or communication, the medical and lay evidence of record does not indicate that the Veteran suffered from persistent hallucinations, disorientation to time and place, or any other symptomatology resulting in total occupational and social impairment. While there is evidence of impairment of short and long term memory, there is no indication that the Veteran had memory loss when it came to names of close relatives, his occupation, or his own name. Additionally, while the Veteran described difficulty establishing and maintaining social relationships, preferring to self-isolate, he reported that he enjoyed participating in church, and spending time with friends which indicates that the symptoms and impairment, while significant, did not more nearly approximate total social impairment. The Veteran’s symptoms and overall impairment thus reflect that his disability picture more closely approximates those contemplated by the 70 percent schedular rating for MDD and not those in the criteria for a 100 percent rating. The preponderance of the evidence thus reflects that the Veteran had neither the symptoms nor overall level of impairment that more nearly approximates total occupational and social impairment, therefore a 100 percent disability rating for the Veteran’s MDD is not warranted. The benefit of the doubt doctrine is not for application in this regard. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). Therefore, referral for extraschedular consideration is not warranted. TDIU The Veteran is currently in receipt of a TDIU from August 20, 2018, the date that he filed a formal claim for TDIU, but he and his attorney contend that a TDIU is warranted from May 4, 2016, the effective date of his grant of service connection for MDD, and as part and parcel of the claim for an initial rating higher than 70 percent for MDD. For the following reasons, the Board agrees. The effective date provisions for awards of increased disability compensation include a general rule which is that an award based on a claim for increase of compensation “shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore.” 38 U.S.C. § 5110 (a). The corresponding VA regulation expresses this rule as “date of receipt of claim or date entitlement arose, whichever is later.” 38 C.F.R. § 3.400 (o)(1). For increased rating claims, if the evidence shows that the increase in disability occurred prior to the date of receipt of claim, the RO may assign the earliest date as of which it is factually ascertainable that the increase occurred as long as the claim for the increased disability rating was received within a year of the date that the increase occurred. 38 U.S.C. § 5110 (b)(3); 38 C.F.R. § 3.400 (o)(2); see also Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (stating that section 5110(b) (2), now section 5110(b)(3), requires that “an increase in a veteran’s service connected disability must have occurred during the one year prior to the date of the veteran’s claim... to receive the benefit of an earlier effective date”). As noted, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel of that claim for a higher rating is whether a TDIU as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this instance, the issue has been raised explicitly and by the evidence of record. To that end, while a TDIU has been granted from August 20, 2018, the issue of entitlement to a TDIU prior to that date, as part and parcel of the claim for a higher initial rating for MDD remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). The fact that the Veteran filed a formal claim for TDIU on August 20, 2018 does not affect the determination that the issue of entitlement to a TDIU was part and parcel of the claim for a higher initial rating for MDD and that the Veteran would be entitled to an effective date of May 4, 2016 if he were unemployable . Harper v. Wilkie, 30 Vet. App. 356, 361-62 (2018) (confirming that when the issue of entitlement to a TDIU is raised as part and parcel of a rating claim, it should be treated separately from a formal claim for TDIU in all aspects of the appeal). Under the applicable regulations, a TDIU may be granted only when it is established that the service connected disabilities are so severe, standing alone, as to prevent the retaining or obtaining of substantially gainful employment. Under 38 C.F.R. § 4.16, if there is only one service connected disability, it must be ratable at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term “unable to secure and follow a substantially gainful occupation” as having two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: the Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. See Van Hoose, 4 Vet. App. at 363. “A high rating in itself is a recognition that the impairment makes it difficult to obtain or keep employment.” Id. The ultimate question, however, is “whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment.” Id. The question of whether the Veteran’s service connected disabilities render him unemployable is a legal determination to be made by the Board. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (“applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner”). Entitlement to TDIU is based on an individual’s particular circumstance. Rice, 22 Vet. App. at 452. Moreover, whether a veteran could perform the physical and mental acts required by employment at a given time is an issue about which a lay person may provide competent evidence. Geib, 733 F.3d at 1354 (“neither the statute nor the relevant regulations require the combined effect [of disabilities] to be assessed by a medical expert”). The Veteran is currently in receipt of service connection for MDD, evaluated as 70 percent disabling from May 4, 2016, thus the Veteran is eligible for consideration for a TDIU on a schedular basis from this date as he has one service connected disability rated 60 percent or more. See 38 C.F.R. § 4.16(a). Nonetheless, to grant TDIU it must be found that the Veteran is unable to secure or follow a substantially gainful occupation because of his service connected disabilities. The Veteran’s VA 21-8940 form indicates that the Veteran became too disabled to work and last worked December 31, 2001. The form reflects that the Veteran last worked in construction, and completed 2 years of college. The aforementioned evidence of record reflects that the Veteran’s MDD symptomatology includes depressed mood, anxiety, near-continuous panic or depression, impairment of short and long term memory, speech intermittently illogical, obscure, or irrelevant, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. In his July 2017 statement, the Veteran reported that he cannot manage to focus, and that his family members say he acts strange and confused. The evidence of record is at least evenly balanced as to whether the Veteran was unable to secure or follow a substantially gainful occupation due to his service connected MDD for the for the period prior to August 20, 2018 and specifically from May 4, 2016. The evidence of record indicates that the Veteran’s MDD symptomatology had not worsened during the period on appeal, and that his impaired judgment, difficulty in adapting to stressful circumstances, and disturbances in motivation and mood would prevent him from performing the requisite duties required of a person with his education and experience working in construction. Thus, the Veteran’s inability to focus on any particular task in his field could reasonably result in serious injury or death to the Veteran or a co-worker. There is no evidence which indicates that the Veteran was qualified for alternative work which would have accommodated his service connected MDD during the period on appeal. For the foregoing reasons, the evidence is thus at least evenly balanced as to whether the Veteran’s service connected MDD precludes him from securing or following a substantially gainful occupation from May 4, 2016. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to an effective date of May 4, 2016, for the grant of TDIU is warranted. 38 U.S.C. § 5107 (b). REASONS FOR REMAND Lower Back and Right Shoulder The Veteran’s friend testified that the Veteran has issues regarding his right shoulder which may be due to overcompensating due to the soreness of his left shoulder. The Veteran’s friend testified that the Veteran had a low back issue that was highlighted during one of the Veteran’s appointments. The Veteran’s friend reported that the Veteran had been complaining about the pain for a while. In a July 2017 medical care questionnaire, the Veteran reported pain in his back among other places, and as previously mentioned, in a July 2017 letter, the Veteran reported falling off the back of moving 5 ton vehicles, stating he felt pain immediately after each event, but that he ignored them. He stated he currently suffers from shoulder, left elbow and lower back pain which has progressively worsened. Unfortunately, the Board cannot make a fully-informed decision on the issues of entitlement to service connection for a lower back disability or right shoulder disability as no VA examiner has opined whether the Veteran has a lower back disability that is related to service, or a right shoulder disability that was related to a service connected disability. For service connection claims, VA is obliged to provide an examination or obtain a medical opinion in a claim when (1) the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a current disability, (2) the record indicates that the disability or signs and symptoms of disability may be associated with service or a service-connected disability, and (3) the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4)(i)(C); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran’s reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. The Veteran has provided competent evidence of a lower back disability via his July 2017 medical care questionnaire, and his friend attested to the Veteran’s right shoulder disability. The Veteran has indicated that the current symptoms may be associated with an in service injury and a service connected disability. However, as the evidence is insufficient to make an informed decision on the claim, a remand for a medical opinion is warranted. Dry Eye Syndrome The Veteran testified that he has suffered from dry eye syndrome since service. The Veteran’s September 1964 medical examination report upon entry notes refractive error, and his September 1964 medical history report reflects that he had an eye operation at the age of 8 to correct an eyelash deformity in 1952. The Veteran’s February 1968 medical examination report upon discharge did not reflect any eye issues, but his February 1968 medical history report reflected that he reported his “eye lashes are hanging on my eyeballs.” His physician noted that the Veteran had surgery for ptosis of the eyelids which interferes somewhat with his vision, and that the Veteran had myopia and wore glasses. May 2014 medical treatment records reflect treatment for dry eyes wherein the Veteran reported duration of more than 10 years. The records reflected a history of trichiasis and entropion repair to the bilateral upper eyelids in 1996. A January 2017 letter from the Veteran’s treating physician reflect that the Veteran was treated for chronic dry eyes and light sensitivity. In an April 2017 letter, the Veteran reported that dry eyes were detected on 2 occasions during his tour of duty in Korea, and that he was issued eye drops. He stated that he continued to have problems with chronic dry eyes throughout service. In a June 2017 letter, the Veteran stated that prior to service he did not have any issues with dry eyes, and that his dry eyes began after he entered the military and has since worsened. A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). In other words, “[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry.” Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Here, the presumption of soundness applies to dry eye syndrome because, while refractive error and an eyelash deformity were noted at entry into service, dry eye syndrome was not noted. The Veteran is therefore presumed sound as to dry eye syndrome. The Veteran has a current diagnosis of dry eye syndrome as evidenced by May 2014 treatment records, and the Veteran has indicated that his dry eye syndrome may be associated with service, testifying that he has had it since service. Again, the Board cannot make a fully informed decision regarding the Veteran’s claim for service connection for dry eye syndrome as no medical opinion has been provided as to the etiology of his dry eye syndrome, thus a remand is necessary for a VA examination to determine whether the Veteran’s dry eye syndrome was at least as likely as not (at least a 50 percent probability) related to service. The matters are REMANDED for the following actions: 1. Obtain an opinion to determine the nature and etiology of any low back disability. If an opinion cannot be obtained without an examination, schedule the Veteran for an examination, to include via telehealth if appropriate, to determine the nature and etiology of any lower back disability. The examiner must opine whether any low back disability is at least as likely as not (at least a 50 percent probability) related to an in-service injury or disease, including the Veteran’s reports of falling out of a truck 2 times during service. A complete rationale should accompany any opinion(s) provided. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. 2. Obtain an opinion by to determine the nature and etiology of any right shoulder disability. If an opinion cannot be obtained without an examination, schedule the Veteran for an examination, to include via telehealth if appropriate, to determine the nature and etiology of any right shoulder disability. The examiner must opine whether any right shoulder disability is at least as likely as not (at least a 50 percent probability) either (a) caused or (b) aggravated by a service connected disability, to include his now service connected left shoulder disability. A complete rationale should accompany any opinion(s) provided. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. 3. Obtain an opinion by an appropriate physician to determine the nature and etiology of the Veteran’s dry eye syndrome. If an opinion cannot be obtained without an examination, schedule the Veteran for an examination, to include via telehealth if appropriate, to determine the nature and etiology of his dry eye syndrome. The physician must opine whether the Veteran’s dry eye syndrome is at least as likely as not (at least a 50 percent probability) related to an in-service injury, event or disease, or had its onset in service. A complete rationale should accompany any opinion(s) provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Maddox, 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.