Citation Nr: 21012360 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-41 592 DATE: March 4, 2021 ORDER Entitlement to service connection for vision problems to include as secondary to service-connected solar urticaria or anxiety/depressive disorder is denied. FINDING OF FACT Vision problems are not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of service discharge, and were not caused or aggravated by the Veteran’s service-connected solar urticaria or anxiety/depressive disorder. CONCLUSION OF LAW The criteria for service connection for vision problems to include as secondary to service-connected solar urticaria or anxiety/depressive disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from March 1999 to September 2000. The Board notes that this claim was previously before the Board in May 2018 and July 2020. At such time, the Board remanded the claim for further development and adjudication. The Board finds there has been substantial compliance with the Board’s remand orders and no further action is necessary. See D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board notes that during the pendency of this appeal, the RO in a November 2020 rating decision granted the Veteran’s claim for entitlement to service connection for dizziness/vertigo. The RO granted such as part of the Veteran’s already service-connected anxiety and depressive disorder and assigned a combined 70 percent rating effective July 23, 2013. The RO noted that it made the rating effective July 23, 2013 as such was the date of the Veteran’s claim for service connection for dizziness/vertigo. The RO noted that such is a full grant of the benefits sought on appeal, therefore such is no longer before the Board. The Board notes that the Veteran had alleged that her dizziness/vertigo should be separately service connected, however as such are now service-connected as part of her anxiety and depressive disorder, such contention is now a rating matter rather than a service connection issue. In addition, as the Veteran has not expressed disagreement with the rating assigned or the effective date, such issue is not before the Board at this time. Entitlement to service connection for vision problems to include as secondary to service-connected solar urticaria or anxiety/depressive disorder is denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that service connection is warranted for vision problems as secondary to her service-connected solar urticaria or anxiety/depressive disorder. The Veteran’s service treatment records are silent for any complaints, treatment or diagnosis of vision problems. However, post-service treatment records reflect the Veteran’s complaints of worsening vision, increased glasses prescription, and pain behind her right eye. Furthermore, the Veteran was diagnosed with impaired vision in approximately December 2012. The Veteran has undergone several VA examinations throughout the appeal, however only examinations and opinions from January 2014, November 2018, July 2020 and October 2020 are pertinent to the Veteran’s claim for service connection for vision problems. In January 2014 the Veteran underwent a private evaluation by Dr. T.A. Dr. T.A. was asked to evaluate the Veteran’s mental health disabilities as well as her multiple sclerosis. The Veteran contended that her vision problems were due to her multiple sclerosis, but that she had been given a diagnosis of solar urticaria during service. Furthermore, the Veteran noted that her solar urticaria included symptoms of vision loss and dizziness. Dr. T.A. opined that the Veteran’s symptoms of dizziness and vision loss were more likely than not caused by her multiple sclerosis. Dr. T.A. did not opine as to whether or not the Veteran’s vision problems were caused by or aggravated beyond their natural progression by her service-connected solar urticaria or anxiety/depressive disorder. In November 2018 the Veteran was provided with a VA Medical Opinion. The examiner opined that the Veteran’s claimed condition was less likely than not proximately due to or the result of the Veterans service-connected conditions. The examiner provided the rationale that the Veteran’s vision problems are manifestations of her multiple sclerosis. The examiner noted that while the Veteran was asymptomatic for decreased vision, diplopia and eye movement pain, she did exhibit progressive thinning of her retinal nerve fiber layer. The examiner noted that studies showed that such was associated with multiple sclerosis. The examiner further noted that the Veteran’s records were consistent with relapsing remitting multiple sclerosis with Uhthoff’s phenomenon, and they found that the Veteran’s eye records, clinical history and brain MRI were consistent with the diagnosis of relapsing remitting multiple sclerosis. The Board notes that the November 2018 examiner did not discuss aggravation in relation to the Veteran’s service-connected disabilities. In July 2020 the Veteran was provided with an additional VA Medical Opinion. The examiner opined that the Veteran’s claimed vision problems were less likely than not caused by or aggravated beyond their normal progression by solar urticaria. The examiner provided the rationale that solar urticaria and other types of urticaria involve the IgE-triggered histamine release found in allergic/atopic reactions. Histamine release is not known to cause the vision impairment described by the Veteran. Furthermore, none of the other physical urticarias cause such effects. The examiner further found that it was less likely than not that the Veteran’s currently diagnosed vision problems were aggravated beyond their natural progression by anxiety and depression. The examiner noted the need for the distinction between disease process and symptoms. The examiner noted that it was likely that the Veteran suffered from somatic symptom disorder however the examiner noted that the current thinking is that underlying somatic symptom disorder increases the negative interplay between the mind and the body but only leads to aggravation through un-needed medical interventions. The examiner noted that the Veteran’s visual disturbance had been diagnosed as a complication of her multiple sclerosis. Furthermore, while anxiety and depression can work through somatic symptom disorder to increase mental suffering as a result of the multiple sclerosis, there is no evidence that the demyelination process is affected. In October 2020 the Veteran was provided with another VA Medical Opinion. The examiner found that it was less likely than not that the Veteran’s vision problems were caused by, proximately due to or aggravated by the Veteran’s service-connected anxiety and depressive disorder. The examiner again noted that the Veteran’s vision problems were due to her multiple sclerosis. Multiple sclerosis is a physical degenerative of the myelin sheath surrounding nerves in the CNS. There is no medical literature supporting the degeneration being actually caused by anxiety or depressive disorders. The examiner noted that unfortunately in the early stages, multiple sclerosis sufferers, are often told “its all in your head,” suggesting that overcoming anxiety would fix any problems. However, the examiner noted that such was not the case, but rather that the degeneration from multiple sclerosis is a physical process not merely “in your head.” Throughout the appeal the Veteran has submitted statements in which she alleges that her vision problems are the result of her service-connected disabilities, specifically her solar urticaria or anxiety/depressive disorder. Furthermore, the Veteran initially claimed that her vision problems were the result of her multiple sclerosis, however the Board notes that the Veteran is not service-connected for her multiple sclerosis and the Veteran subsequently withdrew such claim. The Board notes that the Veteran has not contended, and the evidence does not show, that vision problems had their onset during service, within one year of separation from service, or are otherwise causally related to the Veteran’s military service. In the instant case, the Board finds that an opinion with regard to such matter is not necessary since, as will be discussed below, there is no evidence of the Veteran’s vision problems for many years following service. Furthermore, the Veteran’s service treatment records are entirely negative for any complaints, treatment, or diagnoses referable to vision problems. Furthermore, the record does not show diagnoses of vision problems or impaired vision for many years post-service. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider “all possible” substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, as noted previously, the Veteran claims that her vision problems are secondary to her service-connected solar urticaria or anxiety/depressive disorder, and therefore direct and presumptive service connection are not warranted. As for secondary service connection, the Board notes that all the examiners of record indicated that the Veteran’s vision problems were likely the result of her multiple sclerosis, however as such is not service connected, it cannot form the basis for secondary service connection. Furthermore, the November 2018 and July and October 2020 examiners found that the Veteran’s vision problems were less likely than not caused by her service-connected solar urticaria or anxiety/depressive disorder. Furthermore, while the November 2018 examiner failed to discuss the aggravation prong of secondary service connection, the July and October 2020 examiners specifically found that the Veteran’s vision problems were less likely than not permanently aggravated by her service-connected disabilities. As the July and October 2020 examiners provided sound medical explanations and rationales for their opinions, the Board finds them very probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Furthermore, there are no contrary opinions of record. Therefore, secondary service connection is not warranted. The Board has also considered the Veteran’s statements that her vision problems are related to her service-connected solar urticaria or anxiety/depressive disorder. In this regard, a layperson is competent to report on that of which he or she has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the question of causation or aggravation of vision problems involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, such an opinion requires specialized knowledge of several internal bodily systems. There is no indication that the Veteran possesses such specialized knowledge. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s opinion regarding the etiology of her vision problems is non-probative evidence. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Moreover, the Veteran has offered only conclusory statements regarding the relationship between her vision problems and her service-connected solar urticaria or anxiety/depressive disorder. In contrast, the VA examiners took into consideration all the relevant facts in providing opinions. Therefore, the Board accords great probative weight to the VA examiners’ opinions. Consequently, the Board finds that the Veteran’s vision problems are not shown to be causally or etiologically related to a disease or injury incurred in or aggravated during active service, and were not caused or aggravated by any of the Veteran’s service-connected disabilities, to include her solar urticaria or anxiety/depressive disorder. Therefore, service connection for such claimed disorder 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 Veteran’s claim of entitlement to service connection for vision problems. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Unger, 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.