Citation Nr: 21006375 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 13-32 926 DATE: February 4, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a right eye disability is remanded. Entitlement to service connection for a left eye disability is remanded. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. In July 2019, the Board remanded the claim for the scheduling of a VA medical examination to determine the etiology of the Veteran's claimed hypertension disability. In a subsequent January 2020 VA medical examination report, written in attempted compliance with the Board's remand requests, the Veteran reported experiencing instances of high blood pressure during service. The Veteran indicated that, after a tonsillectomy, he was ordered to stay overnight due to high blood pressure. The Veteran stated that he was first diagnosed with hypertension in 1983, approximately three years after separation from service, and had been taking medication for the disability since 1990. Having reviewed the record, the January 2020 VA examiner opined that the claimed hypertension was not at least as likely as not related to service. The examiner noted that the service medical records included an October 1978 service medical record in which a VA examiner wrote that the Veteran's blood pressure was 152/98 and a September 1979 service medical record in which an examiner found that the Veteran's blood pressure was 130/100. The examiner stated that the aforementioned blood pressure readings were acute and isolated events, taken when the Veteran was seeking treatment for physical ailments. The examiner indicated that there was no chronicity of care for hypertension. The examiner further stated that, in a thorough July 1992 VA medical examination report, a VA examiner noted a blood pressure reading of 132/92 and did not diagnose hypertension. In the January 2020 VA medical examination report, the VA examiner noted that the service medical records contained two noted instances of elevated blood pressure, which the examiner described as acute. However, in the report, the examiner did not note any other blood pressure readings from the Veteran's period of service, to include any normal blood pressure readings. Instead, the examiner indicated that the Veteran's hypertension was not related to service, because, in large part, in a July 1992 VA medical examination report, a VA examiner reported that the Veteran's blood pressure was 132/92 and did not diagnose hypertension. The Board notes that the July 1992 VA medical examination report was written in support of the claims for service connection for low back, foot, tonsil, and eye disabilities. Although the July 1992 VA examiner took a single blood pressure reading during the provision of the examination, the examiner was not examining the Veteran in order to determine whether a hypertension diagnosis was warranted. Moreover, the January 2020 VA examiner did not note that, because the Veteran reported taking medication for hypertension since 1990, the readings taken at the July 1992 VA examination might have been affected by the ameliorative effects of medication. A remand is necessary to schedule an additional examination. 2. Entitlement to service connection for a right eye disability is remanded. 3. Entitlement to service connection for a left eye disability is remanded. In July 2019, the Board remanded the claims for the scheduling of a VA medical examination to determine the etiology of the claimed eye disabilities. In a January 2020 VA eye examination report, a VA examiner diagnosed the Veteran as having bilateral glaucoma, bilateral cataracts, and intermittent estropia without fusion. Having reviewed the record, the VA examiner opined that the claimed eye disabilities were not at least as likely as not related to service, to include an in-service incident during which the Veteran reported experiencing eye trauma due to exposure to a flare. The examiner indicated that, although the service medical records indicated that the Veteran experienced intermittent estropia without fusion during service, those notations were consistent with documented reports that the Veteran had crossed eyes since childhood. The examiner indicated that the condition would not have been noted on the service entrance examination report, because the service examiners who performed that examination did not test binocular vision. In the January 2020 VA eye examination report, the VA examiner indicated that the Veteran's intermittent estropia without fusion dated back to the Veteran's childhood. The examiner did not indicate whether the diagnosed estropia was a developmental disability for which service connection normally may not be established or an acquired disability for which service connection may be established. Moreover, although the examiner indicated that the disability preexisted service, the examiner did not state that the disability clearly and unmistakably preexisted service, as is required for acquired disabilities that were not noted on a service entrance examination. A remand is necessary to schedule an examination. Additionally, a VA treatment record currently in evidence contains a notation indicating that a VA employee scanned a medical record into a VA hospital's imaging system, but do not contain any copies of the scanned record. Any treatment records scanned into a VA hospital's imaging system are within VA's constructive possession and are considered potentially relevant to the issues on appeal. Remand is required to allow VA to obtain that record. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. Specifically, obtain the most recent VA treatment records not included in the record of evidence and the record noted as having been scanned into the Vista imaging system by VA Medical Center personnel, as noted in the VA treatment record in evidence, dated February 29, 2012. 2. Schedule the Veteran for a VA examination for claimed hypertension with a VA medical doctor examiner who has not previously examined the Veteran. The examiner must review the claims file, to include the service medical records, including the October 1978 blood pressure reading of 152/98 and the September 1979 service record blood pressure reading of 130/100; the post-service treatment records including a July 1992 VA examination blood pressure reading of 132/92 when the Veteran has stated he was taking blood pressure medication; and the Veteran's lay statements regarding the etiology of hypertension. The examiner should note the medications taken by the Veteran for the disability and the possible ameliorative effects medications might have throughout the medical history. Having reviewed the record, interviewed the Veteran, and provided an examination, the examiner must provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is related to service, including the documented incidents of elevated blood pressure during service? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension (1) began during active service, (2) manifested within one year after the Veteran’s November 1980 separation from active service, or (3) was noted during service with continuity of the same symptomatology since service? 3. Schedule the Veteran for a VA ophthalmology examination by a VA ophthalmologist. The examiner must review the claims file, to include the service medical records; the post-service treatment records, and the Veteran's lay statements regarding the etiology of all eye disabilities. The examiner should especially note the January 2020 VA eye examination report in which a VA examiner diagnosed intermittent estropia without fusion. Having reviewed the record, interviewed the Veteran, and provided an examination, the examiner must provide the following opinions: (a.) Diagnose all eye disabilities found. (b.) For each diagnosed eye disability, the examiner must opine whether it is a congenital defect, a developmental defect, or is refractive error of the eye. (c.) For each congenital defect or developmental defect, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that each congenital or developmental defect worsened beyond its natural progression due to a superimposed injury or disease during active service, to include the Veteran's reported in-service eye trauma related to exposure to a flare. (d.) Regarding the previously diagnosed intermittent estropia without fusion, if the examiner finds that it is neither a congenital defect or developmental defect, the examiner must opine as to whether the disability clearly and unmistakably preexisted the Veteran’s entrance to active service. If the examiner finds it did clearly and unmistakably preexist service, the examiner should opine as to whether it was clearly and unmistakably not aggravated by service. 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, to include in-service eye trauma related to exposure to a flare. (e.) For each remaining diagnosed eye disability that is neither a congenital defect nor developmental defect, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that each eye disability is related to any event, injury, or disease in service, to include eye trauma related to exposure to a flare. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.M. Gillett 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.