Citation Nr: 21006976 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 12-01 275 DATE: February 8, 2021 REMANDED Entitlement to service connection for an eye disability, to include diabetic retinopathy, bilateral macular degeneration, bilateral cataracts-pseudophakia, bilateral refractive error, and right eye ocular hypertension, as secondary to service-connected diabetes mellitus type II, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from June 1968 to February 1975. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for diabetic retinopathy. In May 2014 and August 2016, the Board recharacterized the issue on appeal as entitlement to service connection for an eye disability, to include diabetic retinopathy, and remanded the matter for additional evidentiary development. In April 2018, the Board sought a medical opinion from the Veterans Health Administration (VHA) in accordance with 38 C.F.R. § 20.901(a) (2018). The requested opinion was received in June 2018 and associated with the claims file. In an August 2019 decision, the Board denied service connection for an eye disability, to include diabetic retinopathy, bilateral macular degeneration, bilateral cataracts-pseudophakia, bilateral refractive error, and right eye ocular hypertension, claimed as secondary to service-connected diabetes mellitus type II. The Veteran appealed the Board’s August 2019 decision to the United States Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, in August 2020, the Veteran’s then-attorney and a representative of VA’s Office of the General Counsel filed an Amended Joint Motion for Remand. In an August 2020 order, the Court granted the motion, vacated the Board’s August 2019 decision, and remanded the matter for action consistent with the joint motion. 1. Entitlement to service connection for an eye disorder, to include diabetic retinopathy, bilateral macular degeneration, bilateral cataracts-pseudophakia, bilateral refractive error; and right eye ocular hypertension, as secondary to diabetes mellitus type II, is remanded. In the August 2020 joint motion, the parties agreed that the June 2018 medical opinion was inadequate as it “was not supported by an adequate rationale pertaining to the aggravation of Appellant’s eye disorders.” Joint motion at page 2. The parties directed the Board to obtain a new VA medical opinion that provides an adequate rationale as to whether it was at least as likely as not that each of the Veteran’s four noted eye conditions -- (1) bilateral macular degeneration, (2) bilateral cataracts-pseudophakia, (3) bilateral refractive error, and (4) right eye ocular hypertension – is aggravated by his service-connected diabetes mellitus. The matters are REMANDED for the following action: 1. Provide access to the Veteran’s claims folder to an ophthalmologist for the purpose of obtaining a medical opinion addressing the following: For each of the Veteran’s noted eye disorders -- (1) bilateral macular degeneration, (2) bilateral cataracts-pseudophakia, (3) bilateral refractive error, and (4) right eye ocular hypertension -- is it at least as likely as not that such disorder had its inception during the Veteran’s active service or is otherwise causally related to his active service? A rationale must accompany the opinion. In providing the rationale, the ophthalmologist must consider the relevant evidence of record, to include service treatment records noting multiple episodes of bacterial infection of the conjunctiva and conjunctivitis, the prescription of eyeglasses for eyestrain and light sensitivity/glare; and treatment for a “rust ring” in May 1973. (Continued on the next page)   If any of the four noted eye disorders were not incurred in or otherwise casually related to the Veteran’s active duty, then the ophthalmologist should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that any of the four noted eye disorders were caused by the Veteran’s service-connected diabetes mellitus. If any of the four noted eye disorders were not caused by the Veteran’s service-connected diabetes mellitus, then the ophthalmologist should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that any of the four noted eye disorders are aggravated by the Veteran’s service-connected diabetes mellitus. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the disability, prior to aggravation. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.D. Hobbs, 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.