Citation Nr: 21006842 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 19-16 293 DATE: February 5, 2021 REMANDED Entitlement to service connection for a disability manifesting in transient vision loss of the right eye, to include ophthalmic migraines or retinal vasospasms, as secondary to service-connected macular atrophy, left eye (left eye disability) is remanded. Entitlement to a higher level of compensation for service-connected left eye disability pursuant to the provisions of the paired organ rule under 38C.F.R. §3.383 (2019) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1958 to August 1959. He testified before the Board at a September 2019 videoconference hearing. A transcript has been associated with the file. The Veteran contends that he should receive compensation for a disability manifesting in transient vision loss of his right eye, arguing that such is secondary to his service-connected left eye disability. As noted by the Board in its prior remand, during the appeal period, the Veteran has advanced two theories of entitlement. On the one hand, he desires his right eye disability to be recognized as service-connected, as secondary to his left eye disability. In the alternative, he has asked VA to consider whether his right eye disability can be compensated based on the paired organs rule, found at 38 C.F.R. § 3.383, arguing that at times his right eye disability is so severe that even though it is not service-connected, it should factor into his overall disability rating for his service-connected vision disability, which currently only involves the left eye. The Board remanded the Veteran’s appeal in November 2019, in pertinent part, to obtain adequate medical opinions addressing the etiology of the claimed disability, to specifically include whether a relationship based on aggravation may exist between the Veteran’s episodic right eye blindness and his service-connected left eye disability. For the reasons discussed below, more complete opinions must be obtained before a fully informed decision can be rendered in this appeal. By way of background, the lay and medical evidence of record demonstrates that the Veteran experiences transient periods of vision loss in the right eye that will result in periods of time where he is completely blind. The Veteran has described an increased frequency of episodic right eye blindness over the years. In his November 2018 notice of disagreement, the Veteran stated that he began to experience episodic blindness in his right eye beginning in 1970. He stated that these episodes continued thereafter, and that they occurred once every month to three months. He stated that these episodes lasted roughly 20 to 30 minutes at a time. In an August 2019 private treatment record, the Veteran reported that his episodes of right eye vision loss began in 1970, and that he experienced one episode every two months. Over the past several years, however, he reported experiencing one episode every three weeks and, more recently, he experienced up to two episodes per day. A September 2019 letter from the Veteran’s VA treatment provider noted that the Veteran suffered episodes of transient vision loss of an increasing frequency. The treatment provider noted that the episodes would last thirty to sixty minutes at a time, and that the Veteran would have “no functional vision (because the left eye already has severe vision loss from a macular scar)” as a result. The treatment provider noted that the Veteran’s episodes of transient vision loss were not the result of his service-connected left eye disability, but rather a consequence of ophthalmic migraines caused by vasospasms. At his February 2020 examination the Veteran reported a frequency of right eye blindness episodes on the average of 3 to 4 times per month, with a duration of 45 to 60 minutes. The examiner noted diagnoses of ocular migraines and retinal vasospasms, and opined against a causal relationship between the Veteran’s service-connected left eye disability and his transient right eye blindness. With respect to aggravation however, the examiner noted the following: Because the left eye is unable to help compensate for the right eye’s vision loss, the left eye chorioretinal scarring is aggravating the Veteran’s functionality during episodes of transient vision loss, however it is not aggravating the duration or intensity of the transient vision loss in and of itself and therefore it cannot be said to be aggravating the condition. The opinion is at best unclear. Moreover, given that treatment reports have identified the Veteran’s ophthalmic migraines and vasospasms as underlying causes of his episodic right eye blindness, the opinion does not adequately address whether the Veteran’s service-connected left eye disability causes or aggravates these underlying causes, as opposed to simply the duration and intensity of the actual vision loss. On remand, a more complete addendum opinion should be obtained. The question of whether a higher level of compensation for service-connected left eye disability pursuant to the provisions of the paired organ rule under 38 C.F.R. §3.383, is intertwined with the outcome of the service-connection claim, and must therefore be deferred at this time. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion addressing the etiology of the Veteran’s transient right eye blindness. The claims file should be sent to, and reviewed by the reviewing clinician. Upon review of the record, the clinician is asked to respond to the following questions: Is it at least as likely as not (50 percent or greater probability) that the Veteran has a disability manifesting in transient right eye blindness, to include ophthalmic migraines and retinal vasospasms, that is caused or aggravated by his service-connected left eye macular atrophy? The questions of causation and aggravation are separate inquiries, and both must be addressed. In providing a response, the examiner should consider whether due to the Veteran’s service-connected left eye blindness, the Veteran must overcompensate with his right eye, and if so, whether this plays a role in causing or aggravating his ophthalmic migraines and/or vasospasms. If there is a medical reason to call into question the September 2019 assessment of the Veteran’s treatment provider, which indicated that the Veteran’s episodic right eye blindness is a consequence of ophthalmic migraines caused by vasospasms, this should be made clear, and an opinion should be provided as to whether the Veteran’s service-connected left eye macular atrophy at least as likely as not causes or aggravates the suspected cause of the right eye blindness. All opinions should be supported by a medical explanation or rationale. 2. Then readjudicate the issues on appeal. If the benefits sought remain denied, in whole or in part, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.