Citation Nr: 21010402 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 07-35 445 DATE: February 24, 2021 ORDER Service connection for an eye disability, to include glaucoma, is denied. FINDING OF FACT The Veteran’s eye disabilities were not first shown until many years following discharge from service, and they are not otherwise due to, or aggravated by, in-service injury or disease, including the service-connected diabetes mellitus and/or hypertension. CONCLUSION OF LAW The criteria for service connection for an eye disability, to include glaucoma, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.  REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1969 to August 1971. This case is before the Board of Veterans’ Appeals (Board) on appeal from a July 2008 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO denied entitlement to service connection for glaucoma. In March 2009, VA received the Veteran’s Notice of Disagreement (NOD). In July 2009, the RO issued a Statement of the Case (SOC). In August 2009, VA received the Veteran’s VA Form 9 appeal to the Board. In January 2012, November 2014, June 2017, and April 2019, the Board remanded the case for further development and adjudicative action. At the outset, the Veteran’s claim for service connection is expanded to include all pertinent eye disabilities. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection 1. Service connection for an eye disability, to include glaucoma. The Veteran seeks service connection for his glaucoma, which has been expanded to include all related eye disabilites. Specifically, he contends that his currently diagnosed glaucoma is proximately due to or aggravated by his service-connected diabetes mellitus and/or hypertension. 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). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service-connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required.  Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013).  In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service.  38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a).  Service connection for a claimed disability may be established on a secondary basis if that disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a).  Establishing service connection as secondary to a service-connected disability requires a current disability that was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a).  Regarding aggravation, 38 C.F.R. § 3.310(b) provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. Service treatment records (STRs) provide no evidence of eye problems during service. Eyes were normal both at entrance and separation from service. See STRs dated April 28, 1969 and April 22, 1971. The Veteran was initially diagnosed with open angle glaucoma in 2006, roughly 35 years after separation from service. See February 2012 VA examination report. Nevertheless, he reported “pain when reading” and vision problems as early as 2001. See primary care note dated April 24, 2001. The Veteran also has diagnoses of incipient senile cataracts, pterygium, and pinguecula. See February 2012 VA examination report. The Veteran believes that he has had diabetes mellitus since at least the 1980s. See April 2008 Veteran statement. However, VA medical records show a diagnosis of diabetes mellitus from approximately 2008 at the earliest. See VA eye consultation note dated February 12, 2008. In addition, in June 2007, the Veteran reported undergoing lab tests for diabetes that month. See June 2007 Veteran statement. See, e.g. eye technician note dated November 22, 2006. However, an April 2008 VA examination for diabetes mellitus failed to yield a diagnosis of diabetes mellitus. Notwithstanding, at the time of the Veteran’s initial diabetes mellitus diagnosis, his glaucoma was described as “advanced.” See VA eye consultation note dated February 12, 2008. The Veteran was diagnosed with hypertension in 1990. See April 2015 VA examination report. A diagnosis of “mild nonproliferative diabetic retinopathy” is also of record. Eye note dated January 25, 2017. However, this is the only notation in the record of any diabetic retinopathy, and it is specifically contradicted by findings from an April 2018 VA diabetic eye examination that indicates no diabetic retinopathy. See also February 2012 and April 2017 VA examinations for diabetes mellitus and a February 2012 eye examination, all of which provide no evidence of eye complications due to diabetes mellitus. More specifically, the April 2017 VA examination report specifically lists complications of the Veteran’s diabetes; and, at that time, the only complications listed were diabetic peripheral neuropathy and diabetic nephropathy/renal dysfunction. The Veteran received a VA examination for his glaucoma in February 2012. The examiner provided a diagnosis of open angle glaucoma. However, she opined that the Veteran’s glaucoma was less likely than not due to or aggravated by the service-connected diabetes mellitus. Regarding causation, the examiner reasoned that the Veteran’s glaucoma diagnosis predated his diabetes mellitus diagnosis. Furthermore, she indicated risk factors of “age, Hispanic origin, thin corneas, a family hx according to progress notes, and a possible risk factor of sleep apnea which some studies have included as a risk factor for decreased perfusion to optic nerve causing glaucomatous damage.” Regarding aggravation, the examiner noted that the Veteran’s glaucoma was advanced at the time of the diabetes mellitus diagnosis and that the glaucoma “has been well-controlled with drops.” In October 2017, the February 2012 examiner submitted an addendum opinion addressing whether the Veteran’s glaucoma was secondary to his service-connected hypertension. She opined that the Veteran’s hypertension was less likely than not due to or aggravated by the Veteran’s hypertension. Regarding causation, the examiner reasoned that, based on review of relevant medical literature, “chronic low blood pressure seems to be a risk for developing progressive glaucoma,” but “high blood pressure (hypertension) does not seem to have as strong relationship”; again, she cited risk factors for glaucoma displayed by the Veteran. Regarding aggravation, the examiner noted that, “the interplay between blood pressure and IOP [interocular pressure] determines the ocular perfusion pressure OPP), which regulates blood flow to the optic nerve.” In this regard, she observed that “high intraocular pressure and low blood pressure both reduce the OPP.” The examiner concluded that, since “hypotension exacerbates the detrimental effects of IOP elevation … hypertension should provide protection against IOP elevation.” Regarding the above, the February 2012 examiner provided fully articulated opinions for both aggravation and causation by the service-connected diabetes mellitus and hypertension. All opinions are supported by reasoned analyses of the Veteran’s medical history and relevant literature. Accordingly, the opinions provider by the February 2012 examiner are afforded significant probative value. Regarding the Veteran’s other eye-related diagnoses, the Veteran does not contend, and the evidence does not show, that his incipient senile cataracts, pterygium, and pinguecula are associated with a service-connected disability or otherwise related to service; all eye disabilities were diagnosed no earlier than approximately 35 years after the service. Furthermore, the singular notation in January 2017 of diabetic retinopathy is outweighed by the VA examinations and other outpatient treatment records revealing no evidence of diabetic retinopathy. Notably, the April 2018 diabetic eye examination confirmed that the Veteran did not, in fact, have any diabetic retinopathy. Although the Veteran believes that his current glaucoma is related to his service-connected diabetes mellitus and/or hypertension, it is well established that a layperson without medical training is not qualified to render medical opinions regarding the etiology of certain disorders. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, as the origin or cause of glaucoma is not a simple question that can be determined based on mere personal observations by a lay person, the Veteran’s lay testimony is not competent to establish a medical etiology or nexus. See Jandreau, 492 F.3d at 1376-77; see also Davidson, 581 F.3d at 1316. Here, it is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer such an opinion. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Therefore, the Board affords his statements as to the etiology of his currently diagnosed glaucoma no probative value. In conclusion, because the preponderance of the evidence shows that the Veteran’s glaucoma and other eye disabilities not related to service, the benefit of the doubt doctrine is not applicable to this case. Accordingly, service connection for an eye disability, to include glaucoma, is not warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Attorney Advisor 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.