Citation Nr: 21006233 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 13-28 294A DATE: February 3, 2021 ORDER Service connection for ocular hypertension, to include as secondary to service-connected hypertension is denied. Service connection for heart disease, to include as secondary to service-connected hypertension is denied. FINDINGS OF FACT 1. Diagnosed ocular hypertension was not incurred in or caused by active service. 2. Ocular hypertension was not caused by or aggravated by service-connected hypertension. 3. Diagnosed coronary artery disease was not incurred in or caused by active service. 4. Coronary artery disease was not caused by or aggravated by service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for ocular hypertension, to include as secondary to service-connected hypertension, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 2. The criteria for service connection for coronary artery disease, to include as secondary to service-connected hypertension, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the U.S. Army from December 1990 to September 1991, with additional service with the Army National Guard prior to his period of active service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office in Montgomery, Alabama (RO). The Veteran testified before the undersigned Veterans Law Judge in a February 2017 video conference hearing. A copy of hearing transcript has been associated with the record. In December 2017, the Board remanded the appeal for VA examinations and medical opinions. The Board finds that substantial compliance was achieved with remand directives and the Board may proceed with a decision at this time. Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff’d, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). On remand, the Board notes that service-connection for cyst in the maxillary sinus cavity was granted within an April 2019 rating decision and as was the claim of service connection for left eye branch retinal vein occlusion (BRVO) and resulting scars. Therefore, these claims are no longer before the Board. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d) (2019). As a general matter, service connection for a disability requires evidence of (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2019). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310 (b) provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. These evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. 38 U.S.C. § 1154 (a) (2012); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102 (2019). When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for ocular hypertension, to include as secondary to service-connected hypertension The Veteran has generally claimed that diagnosed ocular hypertension was caused by service, to include as secondary to service-connected hypertension. The Board notes, again, that left eye BRVO and resulting scars were service-connected in an April 2019 rating decision. Service treatment records show the Veteran had a foreign body in his left eye in July 1981, prior to active service. No matter was shown on visual exam, however, the left eye was irrigated and there was no further irritation after treatment. An August 1990 separation examination Report of Medical History shows the Veteran reported no eye trouble, and a corresponding Report of Medical Examination sows a normal clinical evaluation of the eyes and ocular motility. Private treatment records show the Veteran was seen in September 1992 for blurry vision, and was diagnosed with BRVO of the left eye and had undergone PRP laser treatment of the same. A March 1998 note shows the Veteran’s BRVO of the left eye had resolved status post PRP, and glaucoma was suspected. The Veteran reported that his right eye was unchanged at a distance but reading vision had decreased. VA treatment records show the Veteran was diagnosed with ocular hypertension in February 2011. Within a September 2011 statement, the Veteran indicated that was diagnosed with ocular hypertension and that his VA eye doctor believed his broken blood vessel in service was due to hypertension. Within a February 2017 video conference hearing, the Veteran testified that while stationed in Saudi Arabia, he was exposed to elements like sand, smoke and chemicals. He indicated he went on sick call a few times and remembered having elevated blood pressure. After service, he had issues with is left eye, to include a broken blood vessel in his left eye, which his physician indicted had resulted from hypertension, and he had laser eye surgery within a year of service separation. He stated that over the years, he was told he had glaucoma and used eye drops. In an April 2017 statement, the Veteran’s private physician indicated that the Veteran was under his care for management of hypertension. He reported that a review of the Veteran’s past medical records confirms that there is a correlation between his history of hypertension and heart disease and a 1991 episode of ocular hypertension. The private physician opined that the condition was at least ast likely as not caused by or the result of military service. Attached to this medical opinion were private treatment records, discussed above. A July 2018 VA examination of the eyes showed the Veteran had diagnosed ocular hypertension, cataracts, keratitis sicca and dry eyes. The VA examiner opined that these diagnoses were less likely than not due to the Veteran’s active service, citing that there was no disability in service. Further, the examiner opined that ocular hypertension, cataracts ad keratitis sicca were less likely than not caused by or aggravated by service-connected hypertension. First, the VA examiner indicated that cataracts are likely due to aging and unrelated to hypertension, additionally the Veterans cataracts did not precede the hypertension, as such, they are less likely than not due to the hypertension. Second, keratitis sicca and dry eyes are due to the Veteran’s current environment and not medically related to hypertension. Lastly, ocular hypertension is the elevated pressure inside the eye, caused by the imbalance in the production and drainage of fluid in the eye. The examiner indicated that ocular hypertension is not medically related to hypertension. Regarding any aggravation of the above diagnoses by service-connected hypertension, the examiner indicated that hypertension is not medically related in any way to them. Upon review of all the evidence, lay and medical, the Board finds that ocular hypertension was not incurred in or caused by active service. While service treatment records show the Veteran had a foreign body in his left eye in July 1981, prior to active service, an August 1990 separation examination Report of Medical Examination shows a normal clinical evaluation of the eyes and ocular motility. And, while the Veteran did have diagnosed BRVO of the left eye and had undergone PRP laser treatment in September 1992, shortly after service separation, the Board notes that the Veteran has already been service-connected for this disability. VA treatment records show that the Veteran did not have diagnosed ocular hypertension until February 2011, many years after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). The Board finds probative the July 2018 VA examination and medical opinion of record, in which the VA examiner reviewed the Veteran’s claims file and opined that currently diagnosed eye disabilities were less likely than not incurred in or caused by active service. The Board also finds that ocular hypertension, cataracts, keratitis sicca and dry eyes were not caused by or aggravated by service-connected hypertension. The Board finds probative the July 2018 VA examination and medical opinion, in which the VA examiner reviewed the Veteran’s claims file and opined that currently diagnosed eye disabilities were less likely than not caused by or aggravated by service-connected hypertension. The VA examiner reasoned that: (a) cataracts are likely due to aging and unrelated to hypertension, and additionally, cataracts did not precede the hypertension, as such, they are less likely than not due to the hypertension, (b) keratitis sicca and dry eyes are due to the Veteran’s current environment and not medically related to hypertension: and (c) ocular hypertension is the elevated pressure inside the eye, caused by the imbalance in the production and drainage of fluid in the eye, and is not medical related to hypertension. The examiner further reasoned that hypertension is not medically related in any way to the Veteran’s diagnoses and therefore, such eye disabilities were less likely than not aggravated by hypertension. The Board finds the VA addendum opinion probative as the opinion includes an adequate rationale based on the evidence of record and relevant medical literature. And while an April 2017 private medical opinion indicated that there was a correlation between the Veteran’s history of hypertension and heart disease and ocular hypertension, the Board notes that the private physician did not review the Veteran’s claims file prior to rendering his opinion and did not provide rationale in making his determination. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (The degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file). Therefore, the Board assigns more weight to the July 2018 VA medical opinion. Insomuch as the Veteran contends that his diagnosed eye disabilities are related to service and/or secondary to service-connected hypertension, the Board finds that he is not competent to render such an opinion, as he lacks the medical training and expertise to provide a complex medical nexus opinion. Jandreau v. Nicholson, 492 F.3d 1372, (Fed. Cir. 2007). For the reasons discussed above, service connection for ocular hypertension, to include as secondary to service-connected hypertension is not warranted. Because the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). Service connection for heart disease, to include as secondary to service-connected hypertension Service treatment records do not show complaints, treatment or diagnosis of a heart disability. An August 1991 separation examination Report of Medical History shows the Veteran reported that he did not have heart trouble, palpitation or pounding heart, or high or low blood pressure. A corresponding Report of Medical Examination shows a normal clinical evaluation of the heart, and notes a family history of heart attacks. Private treatment records received in November 2012 show the Veteran was diagnosed with coronary disease in July 2011, and had undergone a left heart catheterization, left and right coronary arteriogram, single plane left ventriculogram, and placement of two stents of the right coronary artery. The post-surgery diagnosis was single-vessel coronary artery disease. Within a February 2017 video conference hearing, the Veteran reported that he was diagnosed coronary artery disease in 2007. He testified that his doctor told him that having high blood pressure in a lot of cases caused heart issues. A July 2018 VA examination and medical opinion shows that the Veteran had diagnosed coronary artery disease. The VA examiner opined that it was not likely that the Veteran’s heart disease was related to his military service. The examiner reasoned that service treatment records did not show heart disease while in service, to include a separation examination and report of medical history. The examiner also opined that heart disease was not likely due to service-connected hypertension. The VA examiner reasoned that the Veteran had a history of obesity hyperlipidemia, cigarette smoking and hypertension. And, at the time of his stent placement for coronary artery disease, it was noted that he had hyperlipidemia, hypertension and a history of tobacco use. The VA examiner cited to medical literature, which states that epidemiological data indicates a strong and consistent link between hypertension and coronary artery disease, however, this does not mean that hypertension is the cause of coronary artery disease. Less than a quarter of the risk of developing coronary artery disease can be attributed to raised blood pressure. Furthermore, in individuals, hypertension is only weakly predictive and hence blood pressure cannot be relied upon to identify those with a particularly high risks. Therefore, the VA examiner concluded that he could not attribute the Veteran’s cardiac disease solely to his hypertension due to the presence of other contributing factors. Lastly, the VA examiner indicated there was no evidence of aggravation, reasoning that the Veteran was diagnosed with coronary artery disease in 2007, and had two stents placed. He had had no further intervention, and a thallium test done in July 2011 was normal, with a normal 2015 stress test. He has not had any further stents place and no evidence of myocardial infarction, so there is no evidence for aggravation of his heart disease. The Board finds that diagnosed coronary artery disease was not incurred in or caused by service. There is no evidence of complaints, treatment, or diagnoses of a heart disability in service, and there is no indication of symptoms, treatment, or diagnoses for coronary artery disease until 2007, many years after service separation. Maxson, 230 F.3d at 1333; Buchanan, 451 F.3d at 1336. The Board finds probative the July 2018 VA examination and medical opinion, in which the VA examiner, upon review of the Veteran’s claim's file, opined that currently diagnosed coronary artery disease was less likely than not incurred in service. The Board also finds that coronary artery disease was not caused by or aggravated by service-connected hypertension. The Board finds probative the July 2018 VA examination and medical opinion, which indicates that coronary artery disease was less likely than not caused by or aggravated by service-connected hypertension. Rather, the VA examiner reported that while epidemiological data indicates a strong and consistent link between hypertension and coronary artery disease, this does not mean that hypertension is the cause of coronary artery disease. The VA examiner was unable to attribute the Veteran’s coronary artery disease solely to service-connected hypertension, due to the presence of other contributing factors such as obesity, hyperlipidemia ad a history of tobacco use. The VA examiner also opined that there was no evidence that coronary artery disease was aggravated by service-connected hypertension because there was normal testing and there were no further interventions since he had stents placed in 2007. The Board finds the July 2018 VA medical opinion probative as the opinion includes an adequate rationale based on the evidence of record and relevant medical literature. Insomuch as the Veteran contends that diagnosed coronary artery disease is related to his service and/or secondary to service-connected hypertension, the Board finds that he is not competent to render such an opinion, as he lacks the medical training and expertise to provide a complex medical nexus opinion. Jandreau, 492 F.3d 1372. For the reasons discussed above, service connection for coronary artery disease, to include as secondary to service-connected hypertension is not warranted. Because the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. R. Woodarek 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.