Citation Nr: 21005786 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 11-32 579 DATE: February 2, 2021 REMANDED Entitlement to service connection for chronic disabilities of the eyes is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2003 to August 2006. The case was previously before the Board in September 2015. At that time the issue was remanded so that the Veteran could give testimony at a formal hearing on appeal In October 2019, a videoconference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran’s claims file. Entitlement to service connection for chronic disabilities of the eyes is remanded. Review of the record shows that, during the hearing on appeal, the Veteran reported having received outpatient treatment. Records of that treatment are not currently of record. A November 2019 Report of Contact indicates that the Veteran has also requested that VA obtain the identified records of treatment. When VA is put on notice of the existence of medical records which may be pertinent to the claim, VA must attempt to obtain those records before proceeding with the appeal. See 38 U.S.C. § 5103A(b); Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992). The record also shows that the Veteran was afforded a VA ophthalmic examination in November 2012. At that time, the examiner stated that the Veteran’s current eye disabilities were not the result of an in-service injury/infection but likely the result of Stephens Johnson syndrome that was believed to have existed prior to the Veteran’s period of active duty. The Board notes that an October 2002 medical history report obtained during the Veteran’s examination prior to his entry into service shows that he had a past history of one episode of this syndrome. The November 2012 examination report did not include an opinion regarding whether the syndrome is shown by clear and unmistakable evidence that the Veteran’s disability existed prior to service and, that the pre-existing disability was not aggravated during service. The Board finds that such an opinion is necessary in this case. See Wagner v. Principi, 370 F. 3d 1089, 1096-97 (Fed. Cir. 2004). The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records referenced during the October 2019 Board hearing and in the November 2019 Report of Contact referenced above. 2. Schedule the Veteran for a VA examination for his chronic eye disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a) Did the eye disability clearly and unmistakably (undebatable) preexist the Veteran’s service? b) If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? c) If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to service, including sun exposure and/or the 2004 right eye injury/infection during service. d) If found to have existed prior to service, did the Veteran’s eye disability at least as likely as not increase in severity during service? e) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph P. Gervasio 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.