Citation Nr: 21012358 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 15-01 393 DATE: March 4, 2021 REMANDED The issue of entitlement to service connection for an eye disability, to include conjunctivitis and/or blepharitis, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1999 to January 2009. In February 2020, the Veteran testified under oath before the undersigned Veterans Law Judge at a travel board hearing. A transcript of the hearing is of record. In February 2020, the Board remanded the appeal for further development. For the reasons outlined below, the Board finds that remand is again needed. The issue has been expanded and recharacterized pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board acknowledges a referral request from the National Personnel Records Center that indicates a request for outpatient treatment records submitted by the Veteran. See Correspondence, November 2020. It appears that VA responded to the Veteran with two different letters, both dated the same day (December 2, 2020). One letter acknowledges receipt of the request for records and notes that it will be processed. However, the other letter states that the request is being returned and that it must first be signed for identification purposes. It is unclear to the Board the current status of this records request, i.e., whether it is pending or rejected. Nevertheless, given the apparent ambiguity, and the fact that the matter is being remanded at this time, the Board will proceed with development of the Veteran’s appeal. Entitlement to service connection for an eye disability. The Board finds that additional development is needed prior to final adjudication of the issue on appeal. Specifically, the Board finds that a new VA examination and opinion are needed. At the outset, the Board notes that in the February 2020 remand, the Board indicated that the Veteran had many complaints regarding his eyes throughout service, including diagnoses of conjunctivitis. See, e.g., STRs, September 1999, March 2005, August 2007, January 2008, and September 2008. The Board directed that an examiner consider “all instances noted in service of treatment for conjunctivitis.” The Board acknowledges the August 2020 VA examination and opinion, but finds that a new examination and opinion are needed for the following reasons. First, the Board seeks clarification of the Veteran’s claimed conjunctivitis diagnosis. The August 2020 VA examination report states that “[t]here is no clinical evidence to support a diagnosis at this time for the claim of conjunctivitis.” However, in June 2011 correspondence, a private physician states that the Veteran “is a patient of mine who has been diagnosed with Acute Sinusitis, Conjunctivitis, and Sleep Apnea.” Further, the August 2020 VA opinion states “that the previous cause of his red eyes was likely allergic conjunctivitis.” At the February 2020 travel board hearing, the Veteran indicated that his conjunctivitis reoccurs every three or four months. The Board asks that an examiner clarify whether the Veteran has had conjunctivitis at any point during the period on appeal, and if so, whether a nexus with service can be established. Here again, the Board points to the numerous complaints of conjunctivitis noted in the service treatment records. In addition, the Board seeks a new opinion that addresses the etiology of the August 2020 VA examination report’s diagnosis of bilateral blepharitis. The August 2020 VA opinion noted “exudates on some of his lashes” and “a history of chalazions,” which “point to blepharitis as the current cause of his recurrent red eyes.” However, this opinion does not address specific eye treatment or complaints in service; it notes only that there is no record of blepharitis or chalazions in service. The Board asks that the specific instances of eye treatment in service be addressed in the new opinion. The matter is REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issue on appeal. In particular, the Board notes treatment from Dr. R.D. Further, the Board notes the following in the Veteran’s travel board hearing transcript, that should be addressed upon remand, if possible. After the Veteran’s hearing adjourned, additional verbiage appears in the hearing transcript, which seems to be some sort of test hearing. Upon remand, the Board asks that this be stricken from the record, if possible. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination to clarify the diagnosis of his claimed eye disability and to address the etiology of any diagnosed disability(ies). For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service. The examiner is asked specifically to address the following in the opinion: (a) Eye treatment in service. See, e.g., STRs, September 1999, March 2005, August 2007, January 2008, and September 2008. (b) The following indications that the Veteran has had a diagnosis of conjunctivitis: (1) the June 2011 correspondence from a private physician that states that the Veteran “is a patient of mine who has been diagnosed with Acute Sinusitis, Conjunctivitis, and Sleep Apnea”; (2) the August 2020 VA opinion that states “that the previous cause of his red eyes was likely allergic conjunctivitis”; (3) the Veteran’s indication at the February 2020 travel board hearing that his conjunctivitis reoccurs every three or four months. The Board asks that an examiner clarify whether the Veteran has had conjunctivitis at any point during the period on appeal, and if so, whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service. Here again, the Board points to the numerous complaints of conjunctivitis noted in the service treatment records. (c) The August 2020 VA examination’s diagnosis of bilateral blepharitis. The VA opinion noted “exudates on some of his lashes” and “a history of chalazions,” which “point to blepharitis as the current cause of his recurrent red eyes.” However, this opinion does not address specific eye treatment or complaints in service; it notes only that there is no record of blepharitis or chalazions in service. The Board asks that the specific instances of eye treatment in service be addressed in the new opinion. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Foster, 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.