Citation Nr: 21007990 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 08-00 166 DATE: February 11, 2021 ORDER Entitlement to service connection for band keratopathy, bilateral pseudophakia, left eye decentration, unreactive left pupil and preretinal fibrosis with diplopia is granted. Entitlement to service connection for left pterygium is denied. Entitlement to service connection for a left knee disorder is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus and/or due to herbicide exposure, is remanded. FINDINGS OF FACT 1. Band keratopathy, bilateral pseudophakia, left eye decentration, unreactive left pupil and preretinal fibrosis with diplopia have been diagnosed during the appeal period and are etiologically related to service-connected diabetic retinopathy. 2. Left eye pterygium is not caused or aggravated by the Veteran’s period of service, is not secondary to a service-connected disorder, and is not caused or aggravated by in-service herbicide exposure. 3. Left knee patellofemoral pain syndrome and degenerative joint disease are not etiologically related to the Veteran’s period of service, did not have onset within one year of separation from service, and has not existed chronically since an in-service onset. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for band keratopathy, bilateral pseudophakia, left eye decentration, unreactive left pupil and preretinal fibrosis with diplopia as secondary to diabetic retinopathy have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for left eye pterygium are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a left knee disorder are not met. 38 U.S.C. §§ 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Army from April 1970 to January 1972, with service in Vietnam from October 1970 to October 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from June 2007 and July 2010 rating decisions of a Department of Veteran’s Affairs (VA) Regional Office (RO). In October 2013, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). Bryant v. Shinseki, 23 Vet. App. 488 (2010). To the extent that any evidentiary deficiency was noted, the Board finds that it has been cured on remand. The Veteran appealed a portion of an August 2017 Board decision that denied entitlement to service connection for hypertension to the United States Court of Appeals for Veterans Claims (Court). In June 2018, the Court vacated that portion of the August 2017 decision that denied entitlement to service connection for hypertension and granted the parties’ joint motion for partial remand. This matter was most recently remanded in March 2020 and October 2020. The Board finds that there has been compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2019). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2019). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Entitlement to service connection for an eye disorder other than diabetic retinopathy. The Veteran alleges that his eye and vision problems were caused or aggravated by his period of service, to include in-service exposure to herbicides. Service connection is already in effect for diabetic retinopathy, and the Board will also address whether any currently diagnosed eye disability is caused or aggravated by the service-connected diabetic retinopathy. First, there are currently diagnosed disabilities. The Veteran has a complicated medical history. December 1990 private treatment records document cataracts with gradually worsening vision since 1988. The findings were assessed as potentially due to vitreoretinal degeneration such as Stickler’s syndrome or Goldmann-Favre syndrome. A January 1991 record reports pre-retinal fibrosis with vitreoretinal traction. The etiology was obscure, the impression was either retinopathy of prematurity or vitreoretinal degeneration such as Stickler’s syndrome. The Veteran underwent right eye cataract surgery in February 1991, and right eye capsulotomy in May 1991 to correct progressive posterior capsular fibrosis. A January 1992 private eye record notes the Veteran had increasing symptomatic cataract of the left eye, status post prophylactic cryotherapy peripheral retinas bilaterally. The Veteran underwent left eye cataract surgery in July 1993 and a capsulotomy February 1995. April 2002 VA treatment notes document suggestive cellophane maculopathy. October 2002 VA treatment notes document the Veteran had extensive epiretinal and preretinal fibrosis, and an October 2003 fundoscopic exam noted preretinal macular fibrosis bilaterally. A September 2006 private record documents a current impression of Stickler’s syndrome, status post cryotherapy to retina, bilateral pseudophakia, status post capsulotomy of both eyes, asymptomatic intraocular lens decentration on the left, and unreactive left pupil suspected due to previous cryotherapy. In August 2008, dilated funduscopic exam showed extensive preretinal fibrosis throughout the central and peripheral retinal of both eyes with fibrous sheets of tissue in the vitreous. April 2009 and April 2010 private treatment records document extensive scarring and preretinal fibrosis throughout the retina of both eyes consistent with Stickler syndrome. May 2013 private records document the Veteran’s complaint of double vision, and the medical provider reported the diplopia appeared to be caused by epiretinal membrane, which was described as a manifestation of the Stickler’s syndrome. March 2015 VA records document the Veteran had proliferative diabetic retinopathy and total retinal detachment bilaterally that appeared regressed and stable. A November 2017 VA examiner noted diagnoses of pseudophakia from 1991 and 1993, and epiretinal membrane status post peeling in 2002. In a May 2019 addendum, the same VA examiner further explained that the Veteran had proliferative diabetic retinopathy and retinal detachments that may or may not have been related to diabetic retinopathy. His only current conditions included pseudophakia and status post epiretinal membrane removal. That examiner explained that the proliferative diabetic retinopathy, retinal detachments, cellophane maculopathy/epiretinal membrane/pre-retinal fibrosis with vitreoretinal traction, and cataracts were treated to resolution. The examiner concluded there was no evidence to support a diagnosis of Stickler’s or Goldmann-Favre syndromes. VA obtained another examination and addendum in October 2020. That examiner diagnosed band keratopathy of both eyes, pterygium of the left eye, and diabetic retinopathy. The Veteran also had preretinal fibrosis of both eyes that contributed the blurry vision and monocular diplopia. The examiner explained the Veteran had presumed Stickler’s vitreoretinopathy in 1990, but subsequent Farnsworth Panel D-15 Color Vision test and ERG/EOG were normal in both eyes and there was no genetic testing to confirm the presence of the syndrome. The examined noted there was no other diagnostic evidence of Stickler’s Syndrome during the appeal period. Though some eye conditions may have resolved during the appeal period, as reported by the VA examiners, the VA and private records nevertheless show they were present at some point during the appeal period. Service connection may be granted for a disease or disability that manifested at any point in the appeal period. From 2006 onward, the Veteran’s eye disorders include bilateral band keratopathy, left eye pterygium, left eye decentration, unreactive left pupil, and cellophane maculopathy/epiretinal membrane/pre-retinal fibrosis with diplopia (hereinafter “pre-retinal fibrosis with diplopia”). Second, the evidence does not show an in-service eye disorder other than bilateral refractive error, and no in-service eye injury. The Veteran is presumed exposed to herbicides and is service-connected for diabetic retinopathy. Thus, while there is no evidence of in-service eye injuries or complaints, there is in-service exposure to herbicides. Third, the evidence demonstrates currently diagnosed band keratopathy, bilateral pseudophakia, left eye decentration, unreactive left pupil and preretinal fibrosis with diplopia are due to the diabetic retinopathy. The preponderance of the evidence indicates the prior surgical procedures were due to diabetic retinopathy as opposed to Stickler’s syndrome. The 2017, 2019 and 2020 VA examiners concluded the Veteran did not have Stickler’s syndrome. The 2020 VA examiner documented that the Veteran’s diabetic retinopathy included a history of cryotherapy and cataract repair. The examiner opined that the band keratopathy was caused by multiple eye surgeries due to diabetic retinopathy. Thus, the evidence demonstrates bilateral band keratopathy is secondary to diabetic retinopathy. Pseudophakia is the presence of intraocular lenses due to cataract repair, thus bilateral pseudophakia is a residual of the service-connected diabetic retinopathy. The evidence also shows left eye decentration and unreactive left pupil, present in 2006 during the appeal period, are also residuals of the prior cryotherapy. See September 2006 private records; see November 2020 VA addendum. The 2020 VA examination report documents the symptoms of the diabetic retinopathy included significant retinal fibrosis and retinal pigment epithelial mottling that contributed to metamorphopsia visual impairment. Thus, the preretinal fibrosis with diplopia is also due to diabetic retinopathy. In sum, the preponderance of the available evidence shows the diagnosed band keratopathy, pseudophakia, left eye decentration, unreactive left pupil and preretinal fibrosis with diplopia are secondary to the service-connected diabetic retinopathy. Entitlement to service connection for pterygium is not warranted. Although the condition is diagnosed, the evidence does not show that the condition had onset in service or is otherwise related to service, including herbicide exposure, or to a service-connected disability. The 2020 examiner adequately explained pterygium was due to ultraviolet light exposure and was therefore unrelated to diabetes or herbicide exposure. Pterygium is also not one of the diseases presumptively associated with herbicide exposure. There is no other evidence in the record to indicate an etiological relationship between the current pterygium and the Veteran’s period of service. Thus, entitlement to service connection for pterygium is denied. 2. Entitlement to service connection for a left knee disorder. The Veteran seeks entitlement to service connection for a left knee disorder. He asserts he had left knee symptoms in service related to overuse. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). There is evidence of left knee patellofemoral pain syndrome and degenerative joint disease of the left knee during the appeal period. Private treatment records dated July 1993 document degenerative changes of the bilateral knees. January 2002 VA x-rays show fragmented anterior tibial tubercle of the left knee perhaps due to previous Osgood-Schlatter’s disease, an April 2002 VA treatment record noted early degenerative changes of both knees, June 2008 x-rays showed left knee mild joint effusion with heterotopic bone formation adjacent to the tibial tuberosity and mild generalized femoral tibial joint space narrowing, and April 2009 private x-rays of the left knee showed small suprapatellar joint effusion with mild medial compartment degenerative change. An October 2017 VA examiner diagnosed left knee patellofemoral pain syndrome. An October 2020 VA examiner reviewed all the radiographic findings and generally characterized the findings as degenerative joint disease of the left knee. Second, the Board finds that there was not an in-service injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran’s STRs are silent for any knee complaints. On his January 1972 report of medical history, the Veteran reported a history of painful or swollen joints, but specifically denied trick or locked knee. The record does show the Veteran also checked “yes” but crossed that response out, and the “no” box is checked instead. He did report other specific problems, such as recurrent back pain and foot trouble. Overall, the objective medical evidence does not show onset of knee symptoms in service or a diagnosed knee condition in service. The Veteran has testified that both knees hurt in service due to frequent jumping. He reported that he did not seek treatment in service due to a culture of not going to sick call. The Board finds the Veteran’s statements to be competent but not credible, due to conflicting evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d,78 F.3d 604 (Fed. Cir. 1996). Significantly, the Veteran denied knee problems at separation although he endorsed other complaints. Accordingly, the Board finds that there was no knee injury or disease during service. Third, the evidence of record fails to demonstrate the diagnosed left knee patellofemoral pain syndrome and left knee degenerative joint disease are otherwise related to service. The October 2017 VA examiner interviewed the Veteran and reviewed the relevant records. That examiner opined that the left knee patellofemoral pain syndrome was not due to the Veteran’s period of service. In support of that opinion, the examiner noted the STRs were silent for any knee complaints or conditions, and there was no evidence of a left knee condition until 1993, many years after separation from service. Rather, the Veteran’s current knee problems were likely related to his post-service career as a plumber and pipe fitter. VA obtained another examination and opinion in October 2020 to address the other left knee diagnoses of record. The examiner reviewed the medical evidence of various left knee conditions and generally summarized the overall condition as left knee degenerative joint disease. The examiner similarly opined that the left knee degenerative joint disease was not etiologically related to the Veteran’s period of service. The examiner also noted there were no knee symptoms, conditions, or injuries documented while in active, and none for many years thereafter. The 2017 and 2020 VA examiners adequately opined the diagnosed left knee disorders were not related to the Veteran’s period of service and there is no medical opinion to the contrary. To the extent the Veteran has expressed a belief his left knee disorders are etiologically related to his period of service, as a lay person he does not have the medical knowledge necessary to provide a medical opinion. Thus, the more probative medical evidence of record weighs against the claim and entitlement to service connection for left knee patellofemoral pain syndrome and left knee degenerative arthritis is denied on a direct basis. Also, entitlement to service connection for degenerative joint disease of the left knee may not be presumed. The medical record does not show chronic left knee symptoms since an in-service onset, and do not show that arthritis manifested to a compensable degree within one year of separation from service. Thus, entitlement to service connection for left knee degenerative arthritis may not be presumed. In sum, the preponderance of the evidence demonstrates the left knee patellofemoral pain syndrome and degenerative joint disease are not related to the Veteran’s period of service. There is no reasonable doubt to be resolved and entitlement to service connection for a left knee disorder is denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus and/or due to herbicide exposure is remanded. This matter is remanded for compliance with the prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The October 2020 remand directed the examiner to specifically address a 2018 NAS/IOM report update showing hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. VA obtained an addendum opinion in October 2020. The 2020 examiner did not address the 2018 NAS study when providing their negative etiology opinion. Thus, remand is required. The matters are REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the hypertension from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that hypertension is caused or aggravated by in-service herbicide exposure. (b.) The examiner must specifically address the more recent 2018 NAS/IOM report update showing hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Smith, 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.