Citation Nr: 21010329 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 19-14 112 DATE: February 24, 2021 ORDER Entitlement to service connection for an eye disability is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s claimed eye disability had its initial onset in service or is otherwise etiologically related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for an eye disability have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1960 and June 1964. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in November 2019. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. See, Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for an eye disability The Veteran contends that his right eye disability is related to his active military service. Specifically, the Veteran contends that his eye disability is directly the result of being punched in the right eye during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Under applicable criteria, VA shall consider all lay and medical evidence of record in a case with respect to benefits under laws administered by VA. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, medical treatment records indicate that the Veteran has current diagnoses of Ptosis and status post macular pucker. Additionally, the Veteran has stated that he was struck in the eye during his active duty service. Accordingly, evidence of an in-service injury has been shown. As the record contains evidence of a current disability, and evidence of an in-service injury or disease, what remains to be established is whether there is a nexus between the diagnosed eye condition and his in-service disease or injury. In a December 2014 statement, the Veteran stated that he was struck in the right eye by a Noncommissioned Officer (NCO) during active service, requiring stitches. The Veteran further stated that he progressively lost eyesight in his right eye over time, and that the only event that could have caused the damage to his eye was the assault by the NCO. The Veteran had an examination for his claimed eye disability in April 2015. The Veteran was diagnosed with ptosis and macular pucker. The examiner opined that the Veteran’s right eye condition was less likely than not related to his active military service. The examiner stated that macular pucker is an idiopathic condition with no known link. In a January 2016 statement, the Veteran reiterated that he was struck by an NCO during service and that although there was no evidence of permanent injury at the time, he has had no other eye injuries since service. The Veteran further stated that he has experienced loss of sight and was told that he had scar tissue on his retina after surgery. In accordance with the November 2019 Board remand, the Veteran had an examination for his eye disability in December 2019. The examiner opined that it was at least as likely as not that the Veteran’s eye disability was related to his active service. However, the examiner also opined that the Veteran’s in-service eye injury resolved without any residual. The examiner stated that the Veteran was treated for a right eye contusion in June 1963. The examiner noted that there were no other ocular abnormalities noted or treated. Additionally, the examiner stated that there was no record during active duty that Veteran was treated for this contusion with stiches as claimed by the Veteran. The examiner opined that it was unlikely that the Veteran had orbital fracture from 1963-1964 and later CT scan result showed fracture to right medial orbit in 2018. The examiner stated that if the Veteran truly had fracture from an original injury in 1963, he would have many ocular issues after the injury. Furthermore, the examiner stated that there were no ocular abnormalities noted during active duty as the condition was resolved without any residuals. In VA treatment records from September 2020, the Veteran’s physician noted that the Veteran had a history of exophthalmos, restrictive myopathy, and partial optic atrophy. The Veteran’s physician stated that the Veteran’s partial optic atrophy could be secondary to his exophthalmos and restrictive myopathy. The Veteran’s physician further noted that the Veteran’s condition may have been from trauma to the right orbit in 1963. In a September 2020 medical opinion, the examiner stated that based on records review alone, the December 2019 examination has multiple inconsistencies, including documentation of visual acuity, spelling errors, conflicting information regarding diagnosis, lack of a dilated eye examination while relying on prior photos in dilated eye exams place. The examiner opined that a complete physical ocular evaluation with extensive attention to Veteran history is necessary. The examiner further noted that the “current information with conflicting recent physical evaluation” is not “adequate to make an informed medical opinion”. The Veteran had another examination for his claimed eye disability in December 2020. The examiner opined that it was less likely than not that the Veteran’s claimed eye disability was incurred in or caused by his active duty service. The examiner stated that the Veteran reported that his progressive vision loss occurred due to one particular incident while on active duty to the right eye. The examiner noted however, that the Veteran has had progressive vision loss in both eyes which was diagnosed after separation from service. The examiner further stated that the Veteran’s statements regarding the in-service incident were inconsistent. The examiner noted that in a statement taken in the sick bay dated June 17, 1963, the Veteran stated, “I was running down steps when I fell”, and at a later time he reported that he received a laceration when a superior officer assaulted him on December 31, 1963, which was later amended to June 17, 1963. The examiner noted that while it is possible that both of these eye-related events occurred on the same day resulting in two separate fractures of the orbit, the patient’s vision loss is from a bilateral condition. In a January 2021 statement, the Veteran explained the discrepancy that he said he fell in-service because he was afraid of retribution from the NCO that struck him. Additionally, the Veteran explained that he simply forgot the specific date that the incident occurred because it happened almost 50 years ago and that the correct date is obviously the one described in his medical records. Further, the Veteran stated that the examiner did not consider the fact that he has had recurring problems with his right eye over several years starting with double vision and followed by retina surgery. The Board finds that entitlement to service connection for an eye disability is not warranted. The Board finds the December 2020 medical opinion to be highly probative. The December 2020 physician provided a detailed opinion based on the pertinent evidence of record, including the Veteran’s lay statements. The December 2020 medical opinion contrasts with the September 2020 physician’s note in the Veteran’s VA treatment records. The September 2020 physician’s note stated that the Veteran’s condition “may have been from trauma to the right orbit in 1963” but did not provide a sufficiently detailed explanation as to how that conclusion was reached. Additionally, the Board does not find the December 2019 medical opinion to be probative. The December 2019 medical opinion does not carry significant probative weight because the opinion is inconsistent and contradictory. As a result, the Board finds the December 2020 medical opinion to carry more probative weight than the September 2020 physician’s note and the December 2019 medical opinion. Furthermore, while the Veteran believes that his claimed eye disability is related to his active military service, specifically his claimed injury from being struck in the eye by an NCO, he is not competent to provide a nexus opinion in this case. The Board notes that this issue is medically complex, as it requires specialized medical education and knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, and of significant probative value, the December 2020 negative opinion was rendered by medical professional with specialized training, who had access to the pertinent medical records. Both descriptions of the incident were considered and still found to not support the current medical findings. Upon review of all of the information, the examiner relied on the fact that the Veteran’s problem is a bilateral one and not the result of a trauma to a single eye. The Board finds this opinion to be the most probative. Accordingly, the December 2020 medical opinion outweighs the lay reports from the Veteran. Based on the foregoing, the Board finds that service connection for an eye disability is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the finding that there is a causal relationship between the Veteran’s current claimed eye condition and his active military service. As such, service connection for an eye disability is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, 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.