Citation Nr: 21009534 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-18 797A DATE: February 22, 2021 REMANDED The issue of entitlement to a compensable rating for bilateral eye disabilities, to include service-connected bilateral cataracts, any diabetic retinopathy, and bilateral eye disorder manifested by cotton wool spots, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1968. The Board previously remanded the issue for further development in May 2019. The case has now been returned to the Board for appellate review. The Board notes that this appeal originates from a February 2014 rating decision implementing the award of service connection for bilateral cataracts and hypertension, secondary to service-connected diabetes mellitus, in a February 2014 Board decision. The Veteran’s complaint and basis for the appeal pertains visual impairment. The Veteran is also service-connected for bilateral dry eye syndrome due to diabetes, which is rated 20 percent disabling. He has also been diagnosed with diabetes with a ‘bilateral eye disorder.” Presumably this contemplates some diabetic retinopathy. Since these remaining eye disabilities are evaluated based on visual impairment and the Veteran is not responsible nor has the medical expertise to determine which disabilities specifically are causing his reported visual impairment, the Board finds that a comprehensive eye examination is needed to ascertain precise visual impairment and any visual field defects that may warrant consideration of a compensable rating, separate from the rating assigned for the dry eyes. Therefore, a medical opinion evaluating a cause of visual impairment must be obtained, for the evidence indicates that the Veteran has some visual field defect and visual fluctuation and they might have been aggravated, via ptosis, by his service-connected dry eye syndrome. A review of the VA treatment records obtained per the May 2019 Board remand indicates that the Veteran complained of vison fluctuations in the left eye when watching TV in August 2019. A treating clinician indicated in a November 2019 VA treatment record that visual acuity fluctuation in the left eye was likely due to dry eye as well as brow/lid ptosis and that ptosis repair was not recommended because it would worsen dry eye. A January 2015 VA examiner stated that the Veteran’s ptosis was causing abnormal visual fields. In addition, a March 2016 VA examiner stated that visual field defects were due to facial features or the patient’s understanding of the test. A July 2016 VA examination reported visual field defect, but it was stated that bilateral ptosis was not affecting vision. The July 2016 examiner did not determine the cause of visual field defect. The most recent visual field testing appeared to have been conducted in March 2019. However, the result of the testing is not associated with the claims file. Thus, a medical opinion ascertaining whether visual field defect is caused by a service-connected disability or it is caused by ptosis, which is aggravated by a service-connected disability must be obtained. Moreover, remand is required in order to afford the Veteran a more recent VA examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997). Caffrey v. Brown, 6 Vet. App. 377 (1994). The last VA examination was conducted in July 2016. Since then, an April 2017 VA treatment record indicates that the Veteran reported having “no longer 20/20 vision off and on” and the vision is worse in the morning and late at night. Also, during the appeal period, the Veteran underwent a punctal plug replacement procedure in January 2016 to address his worsening his dry eye syndrome; the Veteran reported no significant improvement in symptoms after the plugs. Lastly as noted in the May 2019 Board remand, the Veteran’s representative reports that the Veteran’s bilateral eye disability has worsened since the last examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected eye disabilities, to include bilateral cataracts, any diabetic retinopathy, and bilateral eye disorder manifested by cotton wool spots. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must identify all current eye disabilities and all current visual impairments. If there is an additional eye disability that has not been yet determined if it is related to service, the examiner must provide a nexus opinion for such disability. For each visual impairment identified, the examiner must opine whether the impairment is attributed to a service-connected disability. If any of the Veteran’s service-connected eye disability is causing an impairment other than visual impairment, such non-visual impairment must be noted. Moreover, the examiner must also provide an opinion addressing: (a) Whether a visual field defect, if any, is caused by a service-connected disability; and (b) If the examiner determines that the visual field defect is caused by ptosis, whether the Veteran’s dry eye syndrome prevents him from undergoing a correction surgery for ptosis to improve visual field defect or other visual impairment. Additionally, the examiner must specifically determine if the Veteran currently has cotton wool spots due to his diabetes mellitus. The examiner must review the entire claims file, to include this Board remand, before rendering any opinions requested above. A full and complete rationale for all opinions expressed must be provided. 2. After the development requested has been completed, the examination reports should be reviewed to ensure that they are in complete compliance with the directives of this REMAND. If any report is deficient in any manner, corrective procedures should be implemented. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, 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.