Citation Nr: 21008204 Decision Date: 02/12/21 Archive Date: 02/12/21 DOCKET NO. 11-08 401 DATE: February 12, 2021 ORDER Entitlement to an increased rating for bilateral ocular non-Hodgkin's lymphoma with residual retinopathy and pseudophakia, rated as 10 percent prior to October 23, 2019; and 40 percent, thereafter, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), prior to February 27, 2016, is denied. FINDINGS OF FACT 1. Effective prior to October 23, 2019, the Veteran did not have any field of vision impairment; and the Veteran’s distant vision after correction was at worst 20/50 in one eye with 20/40 to 20/50 in the other eye. 2. Effective October 23, 2019, the Veteran’s left eye showed visual field with contraction to 47.875 degrees; and the right eye showed a visual field with contraction to 53.125 degrees; and the visual acuity impairment showed left eye corrected far vision of 20/100 and right eye of 20/70. 3. Effective prior to February 27, 2016, the preponderance of evidence is against finding that the Veteran’s service-connected disabilities resulted in total unemployability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating for bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia, rated as 10 percent prior to October 23, 2019; and 40 percent, thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.75, 4.78, 4.79, 4.80, 4.84a, Diagnostic Codes 6061 to 6080 (2008). 2. Effective prior to February 27, 2016, the criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from February 1966 to January 1970. This matter comes to the Board of Veterans’ Appeals (Board) from a September 2009 rating decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ), which granted service connection for bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy, status post-radiation and chemotherapy treatment, and assigned a noncompensable rating, effective September 9, 2008. In a March 2011 rating decision, the AOJ granted an increased rating of 10 percent, effective September 9, 2008. In January 2015, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing at the AOJ. The Board remanded this case for additional development in February 2015, September 2016, and December 2017. The directives of the Board’s remands having been substantially complied with the case is now returned for appellate review. On remand, in a February 2020 rating decision, the AOJ granted an increased rating of 40 percent for bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia, effective October 23, 2019; and granted entitlement to a TDIU, effective February 27, 2016. As the issue of entitlement to a TDIU was raised as an inferred claim under Rice v. Shinseki, 22 Vet. App. 447 (2009), as part of his initial rating claim for his eye disability, the issue of entitlement to a TDIU prior to February 27, 2016 is still before the Board. 1. Entitlement to an increased rating for bilateral ocular non-Hodgkin's lymphoma with residual retinopathy and pseudophakia, rated as 10 percent prior to October 23, 2019; and 40 percent, thereafter The Veteran claims, in substance, that he is entitled to higher evaluations for his bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia at all times during the appeal because his disability warrants a higher evaluation during this entire time. See, e.g., Notice of Disagreement dated October 2009. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia is rated as 10 percent disabling before October 23, 2019, and 40 percent disabling after October 23, 2019, under Diagnostic Codes 6027 (cataracts)-6066 (impairment of central visual acuity with vision in one eye 10/200 (3/60) or better). Initially, the Board notes that VA’s schedule for rating eye disabilities was revised effective December 10, 2008 and again May 13, 2018, which is during the pendency of this appeal. However, these amended criteria govern cases only where the claim is filed on or after the effective date of the new criteria, unless the Veteran asks that his claim be adjudicated under the new criteria. See 73 Fed. Reg. 66543 (Nov. 10, 2008). In this appeal, as noted in the September 2016 Remand, the claim on appeal was not filed after December 10, 2008, and the Veteran has never asked that his claim be adjudicated under the new criteria. Therefore, the Board must adjudicate this claim applying only the old, pre-December 10, 2008, rating criteria. Prior to December 10, 2008, traumatic cataracts were evaluated under Diagnostic Code 6027. 38 C.F.R. § 4.84a (2008). Preoperative cataracts were to be evaluated based on impairment of vision. Postoperative cataracts were rated based on impairment of vision and aphakia. In rating impairment of visual acuity, the best distant vision obtainable after best correction with glasses was the basis of rating, except in cases of keratoconus, in which contact lenses are medically required. 38 C.F.R. § 4.75 (2008). Further, the severity of visual acuity loss was determined by applying the criteria set forth at 38 C.F.R. § 4.84a (2008). Under these criteria, impairment of central visual acuity is evaluated from noncompensable to 100 percent based upon the degree of the resulting impairment of visual acuity. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a, Table V (2008). Under the old rating criteria, the severity of the Veteran’s eye disability may also be rated based on visual acuity loss under 38 C.F.R. § 4.84a, Diagnostic Codes 6061 to 6079 (2008). In this respect, a 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/40 and vision in the other eye is correctable to 20/50; (2) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, Diagnostic Codes 6078, 6079 (2008). A 20 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/50 or (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/50. 38 C.F.R. § 4.84a, Diagnostic Codes 6077, 6078 (2008). A 30 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in both eyes is correctable to 20/70; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/50; (5) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/40; or (6) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, Diagnostic Codes 6074, 6076, 6077, 6078 (2008). A 40 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/70; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/50; or (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/50. 38 C.F.R. § 4.84a, Diagnostic Codes 6073, 6076 (2008). A 50 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is blind (light perception only) and vision in the other eye is correctable to 20/70; (2) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/70; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/100. 38 C.F.R. § 4.84a, Diagnostic Codes 6065, 6069, 6073, 6076, 6078 (2008). A 60 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is blind (light perception only) and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/100; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/100; (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/100; or (5) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/100. 38 C.F.R. § 4.84a, Diagnostic Codes 6069, 6073, 6076 (2008). Effective prior to December 10, 2008, 38 C.F.R. § 4.84a, Diagnostic Code 6080 (2008) rates loss of vision based on impairment of the field of vision. In this regard, measurement of the visual field will be made when there is disease of the optic nerve or when otherwise indicated. 38 C.F.R. § 4.76 (2008). Under 38 C.F.R. § 4.76a, Table III, the normal visual field extent at the 8 principal meridians totals 500 degrees. The normal field for the 8 principal meridians is as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. Id. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. Id. The number of degrees lost is determined at each meridian by subtracting the remaining degrees from the normal visual fields given in 38 C.F.R. § 4.76a, Table III. The degrees lost are then added together to determine the total number of degrees lost, which are subtracted from 500. The total remaining degrees of the visual field are then divided by eight to represent the average contraction for rating purposes. 38 C.F.R. § 4.76a (2008). Under Diagnostic Code 6080, a 10 percent rating is assigned for concentric contraction of the visual field to 60 degrees, but not to 45 degrees, unilaterally; concentric contraction of the visual field to 30 degrees, but not to 15 degrees, unilaterally; loss of the nasal half of the visual field unilaterally; or loss of the temporal half of the visual field unilaterally. 38 C.F.R. § 4.84a (2008). A 20 percent rating is assigned for concentric contraction of the visual field to 60 degrees, but not to 45 degrees, bilaterally; concentric contraction of the visual field limited to 15 degrees, but not to 5 degrees, unilaterally; or loss of the nasal half of the visual field bilaterally. Id. A 30 percent rating is assigned for concentric contraction of the visual field to 45 degrees, but not to 30 degrees, bilaterally; concentric contraction of the visual field limited to 5 degrees, unilaterally; loss of the temporal half of the visual field bilaterally; or homonymous hemianopsia. Id. A 50 percent rating is assigned for concentric contraction of the visual field to 30 degrees, but not to 15 degrees, bilaterally. Id. A 70 percent rating is assigned for concentric contraction of the visual field to 15 degrees, but not to 5 degrees, bilaterally. Id. A 100 percent disability rating is assigned for concentric contraction of the visual field to 5 degrees, bilaterally. Id. With the above criteria in mind, the Board notes that a July 2008 private treatment letter notes that the Veteran had undergone cataract extraction with intraocular lens implantation to the right eye, with recovering vision. On evaluation, his visual acuity was 20/30 and 20/20. Intraocular pressures were 15 and 17. The pupils showed no afferent pupillary defect. Visual fields were intact. External examination was unremarkable. The examiner noted that the Veteran presented with bilateral ocular lymphoma, status post external beam radiation therapy. A September 2008 VA eye clinic consult shows the Veteran had a history of ocular lymphoma in the right eye. He had radiation and chemotherapy treatments and now had radiation retinopathy in both eyes. He received Avastin injections every 6 to 10 weeks. His visual acuity was 20/50 in the right eye and 20/20 in the left eye. An October 2008 VA treatment record notes that the Veteran was being evaluated for treatment of radiation retinopathy secondary to treatment of ocular lymphoma. He had been receiving Avastin injections at Bascom Palmer with the last injection 10 weeks ago. The impression was primary intraocular lymphoma status post chemotherapy; and radiation retinopathy secondary to the first. In March 2009, a VA treatment record notes no new floaters or changes in vision. An ophthalmology progress note shows visual acuity of 20/40-2 in the right eye; and 20/25+2 in the left eye. A July 2009 VA examination report shows the Veteran had a history of primary intraocular lymphoma and radiation retinopathy worse in the right eye. He also had a history of vitrectomy surgery in the right eye and bilateral age-related macular degeneration. He denied pain, diplopia, or visual field defects. Physical examination showed that the best corrected vision was 20/40 at distance and near in the right eye and 20/25 at distance and near in the left eye. External examination revealed normal findings with eye movements and a grade 4+ afferent pupillary defect in the right eye. Kinetic visual fields obtained revealed constricted peripheral vision in the right eye. Tonometry revealed normal intraocular pressures of 11mmHg in the right eye and 13mmHg in the left eye. Slight lamp biomicroscopy evaluation revealed a posterior intraocular lens with open capsule in the right eye and grade 1+ nuclear sclerotic lens in the left eye. Dilated funduscopic examination revealed an enlarged optic nerve cupping of 0/70 round with grade 2-3+ pallor in the right eye and normal optic nerve findings in the left eye. Macula in the right eye was dry and flat with scattered fine drusen and temporal patches of retinal atrophy greater than 1-disc diameter. Macula in the left eye revealed scattered fine drusen. Posterior pole and peripheral retinal findings revealed scattered hemorrhages and cotton wool spots worse in the right than left eye. The impression was that the Veteran’s reduced central vision in the right eye was most likely caused by age-related macular degeneration. His reduced peripheral vision in the right eye was most likely caused by radiation retinopathy. His reduced central vision in the left eye was most likely caused by a cataract. The examiner found that since diabetes mellitus had been well-controlled for at least the last two years and pre-radiation examinations revealed no diabetic retinopathy, the Veteran’s current retinopathy condition was most likely caused by radiation and chemotherapy treatment. Based on this evidence, the AOJ initially assigned a noncompensable rating for the bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy with consideration of visual acuity findings in one eye of 20/40 and vision in the other eye of better than 20/40. A December 2009 letter from a private eye examination notes that the Veteran had visual acuity of 20/40 in the right eye and 20/20 in the left eye. Intraocular pressures were 15 and 17 respectively. The pupils showed no afferent pupillary defect. Visual fields were intact. The Amsler grid was stable. External examination was unremarkable. The impression was that the Veteran had bilateral ocular lymphoma with asymmetric involvement, right eye greater than left eye. He had radiation vasculopathy and vascular activity bilaterally. It was noted that he would benefit ultimately from cataract extraction and intraocular lens implantation to the left eye with visual compromise. An April 2010 private echographic examination noted mild vitreous opacities and thin, peripheral membranes in the right eye and moderately dense, scatter vitreous opacities and a posterior vitreous detachment (PVD) in the left eye. There was still slight, irregular thickening of the fundus with localized areas of increased reflectivity posterior temporally in the right eye. There was no mass lesion detected in either eye. The retinas were attached and there were no tags or tears seen in both eyes. The impression was macular irregularity in the right eye, unchanged; vitreous opacities and PVD in the left eye, no change; and no mass lesions detected in both eyes. Thereafter, the AOJ assigned a 10 percent rating, effective September 9, 2008, for the bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy based on impairment of central visual acuity of 20/50 in one eye with 20/40 to 20/50 in the other eye. A November 2010 VA eye clinic note shows visual acuity of 20/50 in the right eye and 20/30 in the left eye. The impression was refractive error. The Veteran testified at the January 2015 Board hearing that his right eye was permanently dilated from medications. See January 2015 Board hearing transcript, p. 6. A January 2015 VA eye clinic note shows there were no visual changes noted since last visit. The Veteran was unhappy with his transition lenses due to moderate to severe photosensitivity and wanted to go back to prescription sunglasses. The assessment was refractive errors and radiation retinopathy with history of primary intraocular lymphoma. He also had a history of mild uveitis in the right eye. A June 2015 VA examination report notes that the Veteran had a history of bilateral primary intraocular lymphoma and radiation retinopathy in the right eye, more advanced than the left eye, who underwent treatments for this condition in 2006 consisting of external beam radiotherapy and chemotherapy. Concomitant ocular conditions included nonexudative age-related macular degeneration, nonproliferative diabetic retinopathy in both eyes, and a dilated pupil in the right eye reported to be “fixed” in 2006. He denied ocular pain or diplopia. The assessment was regressed reticulum cell lymphoma in both eyes, no evidence of choroidal or vitreal infiltrative activity in both eyes. There was moderate nonproliferative diabetic retinopathy in the right eye and mild nonproliferative diabetic retinopathy in the left eye. The visual field changes in the periphery in the right eye were likely resultant from radiation retinopathy and central scotoma and might also be from either radiation retinopathy and/ or nonproliferative diabetic retinopathy. There were mild non-specific visual field changes observed in the left eye. In addition, there was mild dry macular degeneration in both eyes. A February 2016 VA addendum report shows that the visual fields in both eyes were essentially full. There were mild superior field cuts in both eyes that might be consistent with upper effects of the Veteran’s upper eyelids. It was recommended that subsequent visual field interpretations be performed by a glaucoma specialist or neuro-ophthalmologist. A June 2016 VA examination report notes that the Veteran had diagnoses of primary intraocular lymphoma in the right eye; radiation retinopathy; and mild bilateral nonproliferative diabetic retinopathy. On physical examination, his corrected near and far vision was 20/40 or better. The Veteran had replacement intraocular lenses in both eyes, postoperative cataract removal. There was no aphakia or discoloration of the crystalline lens. There was no decrease in visual acuity or other visual impairment. A medical opinion was provided that it was at least as likely as not that the Veteran’s diabetic retinopathy was secondary to his diabetes. The Board remanded the case in September 2016 to resolve the conflicting medical evidence in June 2015 and February 2016 noting visual field changes in the left eye, and the June 2016 VA examination noting no visual field defects. A VA examination was provided in November 2016 by a VA optometrist, which noted that the Veteran’s residual vision was decreased in both eyes and was found to be 20/50 in both eyes with best correction. The examiner noted that the Veteran had been treated since 2006 until present with vitreal injections due to macular edema from radiation retinopathy and diabetic retinopathy in both eyes. The chronic edema could come and go and the presence of macular edema that was treated was creating disturbances in the layers of the macular retina and therefore decreasing visual acuity. A June 2017 VA examination report from a VA ophthalmologist shows that the Veteran had mild visual loss noted in the right eye; the left eye saw well. Visual acuity examination showed corrected distance vision of 20/40 or better; and corrected near vision of 20/50 in the right eye and 20/40 or better in the left eye. It was noted that the right pupil was permanently dilated from radiation damage. There was no visual field defect. There also was no contraction of a visual field or loss of a visual field. The Board remanded the case again in December 2017 so that a glaucoma specialist or neuro-ophthalmologist, if possible, or other suitably qualified examiner could provide an examination; so that a claim for entitlement to a TDIU could be adjudicated; and so that the issue of service connection for diabetic retinopathy could be resolved. A May 2019 VA examination report was provided by a VA ophthalmologist. While it was not stated specifically whether this was a neuro-ophthalmologist but the examination provided all necessary information for rating the claim, and the Board remanded stated that the examiner should be a glaucoma specialist or VA neuro-ophthalmologist, if available, or other qualified examiner. It was noted that the Veteran had moderately blurred vision bilaterally. Visual acuity was corrected to 20/50 in distance vision in the right eye; and 20/40 in the left. Corrected near vision was 20/40 in both eyes. There was no visual field defect documented. It was noted that the Veteran had cataracts removed in both eyes and had a replacement intraocular lens (pseudophakia) in both eyes. There was no aphakia or dislocation of the crystalline lens. The decrease in visual acuity was due to retinal atrophy from retinopathy radiation of the retinal lymphoma. The examiner found that the Veteran’s pseudophakia and nonproliferative diabetic retinopathy were both asymptomatic and not causing any visual problems. He had moderately diminished vision bilaterally. It was noted that the Veteran should be able to function fairly well except for seeing very small print and having night vision difficulty. It was noted that the Veteran had retinal atrophy from the retinopathy radiation, which caused his moderately diminished vision and limited visual discrimination to small objects and night vision. It also was noted that employment activities that required fine visual tasks or low light conditions would limit the Veteran’s functioning moderately. An October 2019 VA examination was provided by an optometrist. A Goldmann Perimeter Schema chart also was provided. Again, while it was not stated specifically whether this was an optometrist specializing in glaucoma, the Board remand noted that a glaucoma specialist or VA neuro-ophthalmologist, if available, or qualified examiner should conduct the examiner. There is no indication that the VA optometrist is not qualified to conduct the examination. The examination report noted that the Veteran had progressive decrease in vision due to the non-Hodgkin’s lymphoma in the eyes, which required a Vitrectomy and cataract surgery in both eyes. Current symptoms included blurry vision and decreased night vision in both eyes. The examiner also had chorioretinal scars secondary to the ocular non-Hodgkin’s lymphoma in both eyes. There was no change since onset and not causing vision issues. Visual acuity showed corrected distance vision of 20/70 in the right eye and 20/40 in the left eye. Corrected near vision was 20/100 in the right eye; and 20/40 in the left eye. The Veteran had a decrease in vision due to the cataract surgery in the right eye causing the pupil to be more dilated, which affected the visual focusing of the right eye. There also was chorioretinitis scar in each eye mid-periphery so there was no vision decrease caused. In a February 2020 rating decision, a 40 percent rating was assigned for the Veteran’s eye disability, effective October 23, 2019, based on the examination findings in October 2019 of visual acuity showing left eye corrected far vision of 20/100 and right eye of 20/70; and the left eye showing a visual field with contraction to 47.875 degrees; and the right eye showing a visual field with contraction to 53.125 degrees. It was noted that bilateral concentric contraction of visual field with remaining field of 46 to 60 degrees warranted a 10 percent evaluation; and a 30 percent evaluation was warranted for decrease in visual acuity in the left eye with corrected far vision of 20/100 and right eye of 20/70. The 30 and 10 percent ratings combined to 40 percent, effective October 23, 2019. Under the rating criteria in effect prior to December 10, 2008, when rating impairment of visual acuity the best distant vision obtainable after best correction by glasses will normally be the basis of the rating. 38 C.F.R. § 4.75 (2008). Moreover, the old rating criteria has an exception in cases of keratoconus in which contact lenses are medically required and when there exists a difference of more than 4 diopters of spherical correction between the two eyes. 38 C.F.R. § 4.75 (2008). In those circumstances, the best possible visual acuity of the poorer eye without glasses, or with a lens of not more than 4 diopters difference from that used with the better eye, will be taken as the visual acuity of the poorer eye. Id. In this case, however, there is no evidence indicating that the Veteran has been diagnosed with keratoconus or there being a difference of more than 4 diopters of spherical correction between the right and left eye. Therefore, the Board finds that best distant vision obtainable after best correction by glasses will be the basis of the Veteran’s visual acuity rating at all times during the pendency of the appeal. 38 C.F.R. § 4.75 (2008). With respect to field of vision impairment, prior to the examinations in October 2019 none of the examinations provided indicated any significant impairment in field vision. While a June 2015 VA examination report notes visual field changes in the periphery in the right eye and mild non-specific visual field changes observed in the left eye, the February 2016 VA addendum report shows that the visual fields in both eyes were essentially full. A June 2016 VA examination report also notes that there were no visual field defects. In addition, a June 2017 VA examination report from a VA ophthalmologist shows that there was no visual field defect. There also was no contraction of a visual field or loss of a visual field. Finally, in May 2019, a VA ophthalmologist found that there was no visual field defect documented. Thus, prior to October 23, 2019, there is no evidence of any significant impairment in field vision. Effective October 23, 2019, a rating higher than 10 percent is not warranted for field vision impairment, as the left eye showed visual field with contraction to 47.875 degrees; and the right eye showed a visual field with contraction to 53.125 degrees. These findings warrant a 10 percent rating under Diagnostic Code 6080. There is no evidence of concentric contraction of the visual field to 60 degrees, but not to 45 degrees, bilaterally; concentric contraction of the visual field limited to 15 degrees, but not to 5 degrees, unilaterally; or loss of the nasal half of the visual field bilaterally, which warrants the next higher 20 percent rating under Diagnostic Code 6080. 38 C.F.R. § 4.84a (2008). As for visual acuity impairment, prior to October 23, 2019, the Veteran’s distant vision after correction was at worst 20/50 in one eye with 20/40 to 20/50 in the other eye. As noted, the next higher 20 percent disability rating does not apply unless vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/50; or when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/50. 38 C.F.R. § 4.84a, Diagnostic Codes 6077, 6078 (2008). Thus, prior to October 23, 2019, a rating higher than 10 percent was not warranted for visual acuity impairment. Effective October 23, 2019, the Veteran’s visual acuity showed left eye corrected far vision of 20/100 and right eye of 20/70, which does not warrant a rating higher than 30 percent. The next higher 40 percent rating does not apply unless vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/70; vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/70; vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/50; or vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/50. 38 C.F.R. § 4.84a, Diagnostic Codes 6073, 6076 (2008). Therefore, the Board finds that a rating in excess of 30 percent is not warranted due to loss of visual acuity, effective October 23, 2019. For these reasons, the Veteran’s bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia does not warrant a rating higher than 10 percent prior to October 23, 2019; or higher than 40 percent, thereafter. The Board acknowledges the lay assertions that his eye impairment should warrant higher ratings. However, the Board finds the medical of evidence of record to be more probative because the examinations are based on clinical evaluation of the Veteran and his medical history. The Board has considered the Veteran’s representative’s assertion that an extraschedular evaluation is warranted for the Veteran’s eye disability. See, e.g., November 2017 post-remand brief. Consideration of an extraschedular rating under 38 C.F.R. § 3.321 (b) requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. The Board finds that the quality, frequency, severity, and nature of the Veteran’s visual impairment is adequately contemplated in the schedule. Both decrease in visual acuity and impairment in field vision, effective October 23, 2019, are considered by 38 C.F.R. § 4.84a. Neither the Veteran, nor his representative, have specified which symptoms associated with his eye disability that they consider to be outside the norm for the rating schedule. The evidence also does not indicate that the symptoms and/or manifestations and functional impairments of the Veteran’s eye disability are not fully contemplated in the schedular criteria for the current ratings. Thus, with regard to the first prong of Thun, as noted above, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent, effective prior to October 23, 2019; and in excess of 40 percent, thereafter, for bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a TDIU, prior to February 27, 2016 The AOJ granted entitlement to a TDIU, effective February 27, 2016, in a February 2020 rating decision. However, in light of the claim for his service-connected eye disability, the record reasonably raised the question of whether the Veteran is unemployable due to his service-connected disabilities, and the issue of entitlement to a TDIU rating is part and parcel of the claim for the eye disability prior to February 27, 2016. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Total disability is considered to exist when there is any impairment in mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability, that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any non-service-connected disabilities or the Veteran’s advancing age. 38 C.F.R. §§ 3.341 (a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Substantially gainful employment is defined as work which is more than marginal, and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment is not considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16 (a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstances.” Rice, 22 Vet. App. at 452. When deciding a TDIU claim, the Board “must take into account the individual veteran’s education, training, and work history.” Pederson v. McDonald, 27 Vet. App. 276, 286 (2015). Other than by distinguishing the concept of “substantially gainful employment” from “marginal employment” which “includes but is not limited to employment in a protected environment such as a family business or sheltered workshop” 38 C.F.R. § 4.16, the regulation explaining the criteria for TDIU, does not define “substantially gainful employment.” The Court has recently held that the term “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran’s ability to “follow and secure” employment. For the second component, attention must be given to: (a) the veteran’s history, education, skill and training, (b) the veteran’s physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes the Veteran’s case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. at 363. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). The Veteran’s service connected disabilities are (1) non-Hodgkin’s lymphoma, rated as 100 percent from April 19, 2019; (2) anxiety disorder, rated as 30 percent from January 14, 2015; 70 percent from March 7, 2015; and 50 percent from May 1, 2018; (3) bilateral ocular non-Hodgkin’s lymphoma with residual retinopathy and pseudophakia, rated as 10 percent from September 9, 2008; and 40 percent from October 23, 2019; (4) diabetes mellitus type II, rated as 20 percent from June 1, 2001; (5) diabetic peripheral neuropathy of the right upper extremity associated with diabetes mellitus type II, rated as 20 percent from August 30, 2018; (6) psychophysiologic gastrointestinal reaction, rated as 10 percent from December 2, 1970 to January 14, 2015; (7) tinnitus associated with hearing loss, rated as 10 percent from January 14, 2015; (8) diabetic peripheral neuropathy of the sciatic nerve, right lower extremity, associated with diabetes mellitus type II, rated as 10 percent from August 30, 2018; (9) diabetic peripheral neuropathy of the sciatic nerve, left lower extremity, associated with diabetes mellitus type II, rated as 10 percent from August 30, 2018; (10) diabetic peripheral neuropathy of the femoral nerve, right lower extremity, associated with diabetes mellitus type II, rated as 10 percent from August 30, 2018; and (11) hearing loss, rated as 0 percent from January 14, 2015. The Veteran does not meet the percentage requirements for consideration of a total evaluation under 38 C.F.R. § 4.16 (a), effective September 9, 2008, as his combined disability rating for his service-connected disabilities is 40 percent. However, he meets the criteria for a TDIU, effective March 7, 2015, as his combined rating is 80 percent, and he has at least one disability (e.g., anxiety disorder rated as 70 percent) that are rated as at least 40 percent disabling. Even for the period prior to March 7, 2015, when the required percentage requirements are not met, but the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, the Director of the VA Compensation Service should consider whether a TDIU may be awarded on an extraschedular basis. 38 C.F.R. § 4.16 (b). Under the facts of this case, the Board finds referral is not warranted for the period prior to March 7, 2015; and entitlement to a TDIU on a schedular basis also is not warranted as of that date prior to February 27, 2016. The Veteran noted on his VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability dated in November 2016 that he last worked in construction in March 2015 before he became too disabled to work due to his anxiety disorder, diabetes, diabetic neuropathy, non-Hodgkin’s lymphoma, diabetic retinopathy, and radiation retinopathy. He noted that he had previous work experience as a contractor and two years of college. The Veteran’s former employer submitted a VA-Form 21-4192, Request for Employment Information, noting that the Veteran last worked on February 27, 2016 in construction scheduling. It was noted that the Veteran was unable to sit at a computer for an extended period of time required to complete his scheduling commitment due to diabetic neuropathy and radiation/ diabetic retinopathy. Prior to February 27, 2016, the evidence does not support that the Veteran’s service-connected disabilities resulted in unemployability or precluded all forms of employment based on his working during that time in construction and as a construction scheduler, and as a contractor. While the Veteran stated that he became too disabled to work in March 2015, his former employer noted that his last workday was, in fact, February 27, 2016. The medical evidence of record prior to February 27, 2016, does not show that the Veteran was unemployable due to his service-connected disabilities. For instance, a February 2015 VA mental health examination report notes that while the Veteran had retired two years prior after working for a construction company since 1986, he continued to develop professionally in the construction industry. The Veteran had worked a minimum of 10 to 12 hours per day and continued to do some consulting work. Based on the foregoing, the Board finds that the evidence does not reveal factors outside the norm resulting in unemployability due to the Veteran’s service-connected disabilities prior to March 7, 2015; and entitlement to a TDIU on a schedular basis is not warranted, effective prior to February 27, 2016. For these reasons, the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. As such, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, 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.