Citation Nr: 21005748 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 16-11 513A DATE: February 2, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to his service-connected tinnitus or depressive disorder is denied. Entitlement to service connection for a right eye condition, to include as secondary to his service-connected tinnitus or depressive disorder is denied. FINDINGS OF FACT 1. The Veteran’s hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury or disease; and the hypertension is not secondary to service-connected tinnitus or depressive disorder. 2. The Veteran’s right eye condition is not secondary to service-connected tinnitus or depressive disorder and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, to include as secondary to his service-connected tinnitus or depressive disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for a right eye condition, to include as secondary to his service-connected tinnitus or depressive disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marines Corps from August 1961 to August 1965. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in June 2018. A transcript of the proceeding has been associated with the claims file. The Veteran’s claims were previously remanded by the Board in a July 2018 decision. The Board directed the RO to ask the Veteran to complete a VA Form 21-4142 for any additional private treatment records, obtain updated VA treatment records from March 2015 to the present, and to schedule VA examinations for both the hypertension and right eye condition claims. A Subsequent Development Letter was sent to the Veteran in August 2019 requesting information about any additional private treatment records; however, the Veteran did not respond to the letter. Updated VA treatment records were added to the file. VA examinations were scheduled for the Veteran in October 2019, September 2020, and October 2020. Therefore, the Board finds that the RO has substantially complied with the July 2018 Board remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).   1. Entitlement to service connection for hypertension, to include as secondary to his service-connected tinnitus or depressive disorder The Veteran contends that his hypertension started in service. Alternatively, the Veteran contends that his hypertension is due to his service-connected tinnitus. The Board finds that the Veteran has a diagnosis of hypertension as evidenced by a May 2018 Disability and Benefits Questionnaire completed by Dr. B.A. The Veteran’s physician determined that the Veteran was diagnosed with hypertension in 2011. Thus, the Veteran has a current disability. The Board also notes that hypertension is a chronic disease pursuant to 38 C.F.R. § 3.309. The first question before the Board is whether the Veteran’s hypertension was shown as chronic in service, manifested to a compensable degree within a presumptive period, or was noted in service with attributable continuity of symptomatology. The Veteran’s service treatment records do not contain any complaints, treatment, or diagnoses related to hypertension. The Veteran’s July 1965 separation examination noted that the Veteran’s heart and vascular systems were normal and recorded his blood pressure as 100/70. The Veteran’s post-service medical records do not include any notations for hypertension until March 2011 after he underwent pterygium surgery. At the time, his blood pressure was elevated, and he was prescribed Lisinopril to get his blood pressure down. The Veteran was afforded a VA examination in October 2019. The VA examiner opined that the Veteran’s hypertension less likely than not manifested in service or within one year of discharge. The rationale provided was that the Veteran’s service treatment records do not show elevations of blood pressure, his separation examination shows blood pressure at 100/70, and there was no diagnosis of hypertension in service or within one year of service. The Veteran was diagnosed with hypertension decades after his separation from service. The Board finds that the preponderance of the evidence is against finding that the Veteran’s hypertension was shown as chronic in service, manifested to a compensable degree within one year of separation from service, or was noted in service with attributable continuity of symptomatology. The medical records indicate that the Veteran was diagnosed with hypertension nearly 46 years after he separated from service. His service treatment records do not indicate a diagnosis of hypertension or elevated blood pressure during service. Additionally, the Board finds the October 2019 VA examiner’s opinion to be probative and thoroughly supported by the evidence of record. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that service connection for hypertension on a presumptive basis is not warranted. 38 C.F.R. § 3.307. The second question before the Board is whether the Veteran’s hypertension is at least as likely as not related to an in-service injury, event, or illness. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. In September 2020, a VA examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that all documentation of hypertension was after service and there are no records to support a finding that the Veteran’s hypertension was incurred in or caused by service. The examiner cited to the Veteran’s July 1965 separation examination, which notes “normal” heart and vascular systems and blood pressure at 100/70. The Board finds the opinion to be adequate and probative as it is based on an accurate medical history and provides an explanation that contains clear conclusions with supporting data. See Nieves- Rodriguez, 22 Vet. App. 295. While the Veteran believes his hypertension is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical knowledge of the interaction between multiple organ systems in the body and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent September 2020 VA examination. Accordingly, entitlement to service connection for hypertension on a direct basis is not warranted. 38 C.F.R. § 3.303. The final question before the Board is whether the Veteran’s hypertension is at least as likely as not proximately due to or aggravated by a service-connected condition to include tinnitus or depressive disorder. In an April 2012 opinion provided by the Veteran’s eye doctor, Dr. J.M.B., he opined that the Veteran’s blood pressure may also be related to perceived stress caused by significant hearing damage in the right ear. Dr. J.M.B. cited to multiple reports in the literature correlating stress with increased blood pressure. In an October 2019 VA examination, the VA examiner opined that the Veteran’s hypertension is less likely than not proximately due to or the result of the Veteran’s service-connected tinnitus or depressive disorder. The rationale provided was that to date, there is no study or evidence/documentation to relate tinnitus or depression as causative etiology for hypertension. The examiner further opined that neither tinnitus nor depression are one of the known causes of secondary hypertension. An addendum opinion was also completed in October 2019. The examiner again found that the Veteran’s hypertension is less likely than not proximately due to or aggravated beyond its natural progression by service-connected tinnitus or depressive disorder. The rationale provided was that tinnitus and depression have not been causally associated with hypertension. The examiner referred to the April 2012 opinion provided by Dr. J.M.B. noting that it tries to make a nexus connecting the Veteran’s ear problems causing stress and this in turn causing hypertension. The examiner stated that this is not supported by medical literature, and although it is true that there are multiple reports in the literature correlating stress with increased blood pressure, correlation does not mean causation. The examiner opined that the relationship between stress and blood pressure is with isolated elevation of the blood pressure, not with sustained elevation of the blood pressure, which is the cause of the Veteran’s hypertension. As for aggravation, the examiner explained that hypertension in this Veteran is not aggravated, it has followed the natural progression as evidenced by his medical records which show there is a fair control in current medications. Most recently, in October 2020, another VA medical opinion was obtained. The examiner opined that the Veteran’s hypertension is less likely than not proximately due to his service-connected tinnitus and depressive disorder since there is no chronological, causal relationship of hypertension and service-related tinnitus or depression. The examiner also noted that there is no peer reviewed medical precedence to support such premise. As for aggravation, the examiner opined that the Veteran’s hypertension is less likely than not aggravated beyond is natural progression by his service-connected tinnitus or depressive disorder since there is no aggravating relationship of hypertension and service-related tinnitus or depression. The examiner again explained that there is no peer reviewed medical precedence to support such premise. After careful consideration of the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran’s hypertension is proximately due to or aggravated by his service-connected tinnitus or depression. The Board finds that the VA medical opinions provided in October 2019 and October 2020 are adequate and probative, and supported by the facts of the case. See Nieves- Rodriguez, 22 Vet. App. 295. Specifically, the Board finds that the addendum opinion provided in October 2019 is highly persuasive and supported by clear conclusions and medical data. The VA examiners also concluded that the Veteran’s hypertension is less likely than not proximately due to or aggravated by the Veteran’s tinnitus or depressive disorder as there is no medical literature to support a causal relationship between the conditions. The Board has considered Dr. J.M.B’s April 2012 opinion, where he indicated that the Veteran’s blood pressure may also be related to perceived stress caused by significant hearing damage in the right ear. (emphasis added). However, in the July 2018 Board remand, the Board concluded that the April 2012 opinion was insufficient as the opinion is speculative and not supported by a rationale. Obert v. Brown, 5 Vet. App. 30, 33 (1993). Furthermore, the opinion was offered by the Veteran’s eye doctor who does not specialize in matters of the heart or vascular systems, but of the eyes. Additionally, the October 2019 examiner who provided the addendum opinion noted that the medical literature does not support Dr. J.M.B.’s opinion regarding a causal relationship between stress and sustained elevated blood pressure. Thus, the Board finds that the opinion lacks probative value and assigns more weight to the VA medical opinions. The Board has also considered the Veteran’s contentions that his blood pressure is related to his tinnitus. As a lay person, however, the Veteran has not shown that he has specialized training sufficient to render such an opinion or diagnosis. See Jandreau, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). Consequently, the Board gives more probative weight to the competent medical evidence of record. Accordingly, entitlement to service connection for hypertension as secondary to service-connected tinnitus or depression is not warranted. 38 C.F.R. § 3.310. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine does not apply. Gilbert, 1 Vet. App. at 54; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a right eye condition, to include as secondary to his service-connected tinnitus or depressive disorder The Veteran contends that his right eye condition is secondary to his tinnitus. The Board finds that the Veteran has a diagnosis of non-arteritic ischemic optic neuropathy (NAION) of the right eye. This condition was diagnosed in March 2011 as evidenced by an April 2012 private medical record from Dr. J.M.B. Thus, the Veteran has a current disability. Although the Veteran did not specifically allege that his right eye condition was due to his service, the Board finds that a direct service connection analysis is still warranted. Thus, the first question for the Board is whether the Veteran’s currently diagnosed NAION of the right eye began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnoses related to the right eye. His July 1965 separation examination noted that his eyes were “normal.” The Veteran’s private treatment records first reveal a right eye condition in March 2011. The Veteran underwent pterygium surgery and then experienced loss of vision in the right eye thereafter. Dr. M.R. evaluated the Veteran at the time and opined that the primary pathology in the Veteran’s right eye was ischemic optic neuropathy with swelling of the nerve causing secondary venous stasis. The doctor further stated that the Veteran’s eye looked like malignant hypertension and advised that the Veteran begin his blood pressure medication. In an April 2012 letter, another doctor, Dr. J.M.B., concluded that the Veteran’s NAION condition was due to increased blood pressure and a hypertensive episode. He also stated that the Veteran’s blood pressure may also be related to perceived stress caused by significant hearing damage in the right ear. Dr. J.M.B. noted that there are multiple reports in the literature correlating stress with increased blood pressure and he believes that this is related to his unfortunate eye pathology. The Veteran was afforded a VA examination in September 2020. The examiner confirmed the Veteran’s diagnosis of NAION in the right eye and opined that his eye condition was less likely than not incurred in or caused by the claimed in service injury, event, or illness. The rationale provided was that the condition NAION was less likely than not incurred in or caused by an event in service from a review of the service treatment records and is most likely caused by the Veteran’s hypertension. The examiner further noted that the most common systemic disorders associated with NAION are hypertension and diabetes mellitus. After a review of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that the Veteran’s right eye NAION began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran’s service treatment records are silent for any right eye condition in service. The Veteran’s was not treated for or diagnosed with a right eye condition until March 2011, decades after he separated from service. Furthermore, Dr. M.R. in March 2011, Dr. J.M.B. in April 2012, and the September 2020 VA examiner all opined that the Veteran’s right eye NAION is related to his hypertension and not any in-service events. Accordingly, service connection for a right eye condition on a direct basis is not warranted. 38 C.F.R. § 3.303. The next question before the Board is whether the Veteran’s right eye NAION is at least as likely as not proximately due to or aggravated by a service-connected condition to include tinnitus or depressive disorder. The Veteran was first afforded a VA examination in April 2013. The examiner opined that Veteran’s right eye condition is not at least as likely as not proximately due to or the result of his tinnitus. The rationale provided was that the two conditions, although both on the right side, are separated by at least 46 years and are not related to each other. The examiner noted that the Veteran reported tinnitus after a hand grenade exploded next to his right ear in service. In October 2019, the Veteran was afforded another VA examination. The examiner opined that the condition claimed is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner also opined that the Veteran’s right eye condition is less likely than not manifested in service and also was not proximately due to service-connected tinnitus or depressive disorder, and the condition was less likely than not aggravated beyond its natural progression by service-connected tinnitus or depressive disorder. The rationale provided was that NAION is the result of vascular insufficiency and ION refers to all ischemic causes of optic neuropathy. The examiner noted that the most common systemic disorder associated with non-arteritic anterior ION are hypertension and diabetes mellitus. Another VA medical opinion was obtained in September 2020. The examiner determined that a review of the Veteran’s records reveals that the Veteran’s eye condition of NAION with vision loss is less likely than not due to his tinnitus, depression, or anxiety. The condition however is at least as likely as not due to his hypertension as hypertension is a known risk factor for NAION. An addendum to the September 2020 VA examination was completed in October 2020. The examiner opined that the Veteran’s right eye condition was aggravated by his non service-connected hypertension and not from his service-connected tinnitus or depressive disorder. The rationale provided was that the Veteran has ischemic optic neuropathy of which hypertension is a well-known risk factor. Tinnitus, an ear problem, and depressive disorder, a psychological issue, have no connection to the right eye condition according to the VA examiner. The Board has considered the opinions offered by the VA examiners offered in April 2013, October 2019, September 2020, and October 2020 and finds that the cumulative findings of the VA examiners are adequate and highly probative as the opinions are based on an accurate medical history and provide explanations that contain clear conclusions with supporting data. See Nieves- Rodriguez, 22 Vet. App. 295. It is significant to note that none of the VA examiners opined that the Veteran’s right eye condition was proximately due to or aggravated by the Veteran’s service-connected tinnitus or depressive disorder. The Board also cites to the fact that all the VA examiners and the Veteran’s private physicians, in March 2011 and April 2012, opined that the Veteran’s right eye condition was more likely related to his hypertension, which is not service connected. The Board has considered Dr. J.M.B’s April 2012 opinion, where he indicated that the right eye condition may also be related to perceived stress caused by significant hearing damage in the right ear. (emphasis added). However, as previously noted, the Board concludes that the opinion is inadequate. Thus, the Board finds that the opinion lacks probative value and assigns more weight to the VA medical opinions as well as the March 2011 opinion provided by Dr. M.R. The Board has considered the Veteran’s spouse’s March 2013 contentions and the Veteran’s June 2018 contentions that his right eye condition is secondary to his service-connected tinnitus. However, neither the Veteran nor his spouse have demonstrated the medical knowledge or training to offer a competent nexus opinion regarding this issue. Jandreau, 492 F.3d at 1377; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the overwhelming amount of medical evidence that indicates the Veteran’s right eye condition is related to his hypertension and not his service-connected tinnitus. Accordingly, entitlement to service connection for a right eye condition on secondary basis is not warranted. 38 C.F.R. § 3.310. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine does not apply. Gilbert, 1 Vet. App. at 54; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hartford, 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.