Citation Nr: 21013973 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 10-25 449 DATE: March 11, 2021 ORDER Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected right shoulder disability, is denied. Entitlement to service connection for left and right eye disorders is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s left shoulder disorder is related to service. 2. The preponderance of the evidence is against finding that the Veteran’s right eye melanoma or left eye blepharitis, pseudophakia, hyperopia, astigmatism, or presbyopia is related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected right shoulder disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for left and right eye disorders have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1941 to October 1945. He served honorably in the U.S. Army, including service in the Aleutian Islands during World War II. The Board is thankful for the Veteran’s service to our country. Unfortunately, the Veteran died in April 2015, during the pendency of his appeal. The Agency of Original Jurisdiction and the Board have recognized his surviving spouse as the substitute claimant for the purposes of processing these claims to completion. The Board previously remanded this case in September 2017, November 2019, and March 2020 for additional development. The case has now returned to the Board for further appellate review. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition to direct service connection, service connection is also warranted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish secondary service connection there must be evidence: (1) of a current disability (for which secondary service connection is sought); (2) of an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected right shoulder status post rotator cuff repair with torn biceps muscle. In a February 2008 Statement in Support of Claim, the Veteran contended that service connection for a left shoulder disorder is warranted, as right shoulder weakness resulted in left shoulder overuse. After reviewing the evidence, the Board finds that service connection is not warranted. A review of the Veteran’s service treatment records (STRs) shows that the Veteran complained of injuries to his right shoulder while in service, but STRs are silent for any complaints, treatment, or diagnosis for a left shoulder injury. Post-service records confirm the same as evidenced in a June 1991 VA examination where the Veteran reported injuring his right shoulder, neck, and left knee in an incident with a tractor. He reiterated this same injury in September 1991 and June 2002 Statements in Support of Claim. In a June 2011 VA joints examination, the examiner rendered a diagnosis of “left shoulder, likely arthritic changes normal for age.” The examiner noted that while the Veteran is claiming a left shoulder injury, the Veteran denied having a “left shoulder condition.” Physical examination showed no left shoulder pain on range of motion testing and the examiner noted that the Veteran had no specific left shoulder injury or condition other than “mild degenerative changes over a lifetime.” The examiner remarked that there is some rationale for aggravation of the left shoulder with decreased use of the dominant right shoulder, but concluded that, as the Veteran had good range of motion and no specific weakness, the Veteran did not have a left shoulder disability. The Board notes that medical opinions were obtained in March 2018 and December 2019 to determine the etiology of the Veteran’s left shoulder disability. However, these opinions were deemed inadequate in the Board’s November 2019 and March 2020 decisions, respectively. Nonetheless, in an October 2020 VA addendum opinion, the clinician concluded that it is less likely than not that the Veteran’s left shoulder disorder, to include arthritis, was proximately due to his service-connected right shoulder disability. The clinician explained that arthritis occurs when the protective cartilage that cushions the ends of the bones wears down and gradually deteriorates. She explained that this is usually associated with the normal effects of aging. The clinician further noted that the Veteran’s June 2011 x rays showed degenerative changes which were normal for his age, and that the medical record is silent of any indication that the Veteran had overcompensated and aggravated his left shoulder. Based on the above, the Board finds the preponderance of the evidence is against finding that the Veteran’s left shoulder disorder was caused by his service-connected right shoulder disability. The Board finds the October 2020 medical opinion is the most probative evidence of record since the examiner’s opinion was based on a review of the Veteran’s medical history and the opinion was supported with clear medical rationale. The Board recognizes the Veteran’s contention that his left shoulder disorder was the result of overuse due to right shoulder weakness; however, the Veteran as a lay person does not have the medical expertise required to determine a diagnosis or etiology for his left shoulder disability. Although not contended by the Veteran, the Board also finds that the Veteran’s left shoulder disability was not caused by any event or injury in service. As noted above, STRs are silent for a left shoulder condition. In addition, the Board notes that in his June 2011 VA examination, the Veteran reported injuring his left shoulder during a tractor incident in service; however, this is inconsistent with his earlier reports in 1991 and 2002 where he reported injuring his right shoulder. Furthermore, the Veteran’s June 2011 x-rays showed degenerative changes that were normal for his age, and treatment records show the first complaint of left shoulder pain occurred in September 2012. Thus, there are no continuity of symptoms or treatment that would indicate the Veteran’s left shoulder degenerative changes were caused by service. Hence, the Board concludes that the preponderance of the evidence is against finding that service connection for a left shoulder disorder, to include as due to the service-connected right shoulder disability, is warranted. The Board has considered the doctrine of reasonable doubt; however, the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. Gilbert, 1 Vet. App. at 55; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for left and right eye disorders is denied. The Veteran contended that his left and right eye disorders were due to an in service traumatic brain injury sustained during the cave-in in the Aleutian Islands. The Board finds that service connection is not warranted for left and right eye disorders. Refractive errors of the eyes (including presbyopia, myopia, and astigmatism) are congenital or developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990). A review of the Veteran’s STRs shows that on entrance, the Veteran was noted to have 20/30 vision bilaterally. Subsequent STRs show notations of eye strain. In addition, snow blindness was noted in his separation examination; however, the examiner indicated by omission that it would not result in disability. Right and left eyesight was noted to be 20/50 and 20/40 uncorrected, respectively; and 20/40 corrected, bilaterally. In a March 1948 VA examination report, the examiner noted that the Veteran’s eyes appeared normal and corrected vision was 20/20 in each eye. Alternatively, in a February 1953 VA examination report, the examiner noted that his eyes were markedly hyperopic. An August 1997 VA treatment record shows the Veteran had a history of melanoma in the retina of the right eye. In a December 2002 treatment record it was noted that the Veteran’s right eye had been enucleated two weeks prior due to melanoma. A subsequent treatment record from May 2010 shows the provider rendered assessments of pseudophakia, hyperopic astigmatic presbyope, and mild macular retinal pigment epithelial mottling of the left eye. Similarly, in a March 2012 treatment note, the provider rendered assessments of pseudophakia, dry eye secondary to blepharitis, hyperopia, astigmatism, and presbyopia of the left eye. With regard to the etiology of the Veteran’s bilateral eye disabilities, the record shows a May 2008 letter from a private physician, who appears to specialize in vitreoretinal surgery and diseases, found that the Veteran’s right eye injury was related to service. The physician stated that the Veteran’s medical records had been reviewed and that as a result of an Army vehicle accident, the Veteran sustained traumatic injuries to his brain, shoulder, knees, and hands. The physician further found that the Veteran developed vision loss in his right eye and concluded this was likely secondary to the event. In a December 2019 VA medical opinion, the clinician concluded that the Veteran’s right eye melanoma is less likely than not related to in-service snow blindness. The clinician explained that snow blindness is a sunburn of the cornea of the eye and like other sunburns, usually resolves within a day or two. The clinician added that the role of ultraviolet light as a risk factor is unclear and that epidemiological studies of the association between ultraviolet light and uveal melanoma have yielded mixed results, but concluded that the melanoma is less likely than not related to a single episode of corneal sunburn. The clinician concluded that there was no diagnosis for a left eye disorder in the service treatment records or in the medical records. In an October 2020 addendum opinion, the clinician, an optometrist, concluded that the Veteran’s left eye disorders were less likely than not related to service. The clinician noted that blepharitis and dry eye were diagnosed in 2012 and subsequent records were silent of the condition. The clinician further noted that blepharitis commonly occurs when tiny oil glands of the inner eyelid become inflamed. In addition, the condition can occur when there is too much bacteria on the eyelids at the base of the eyelashes, and it may also occur oil glands in the eyelids become clogged or irritated. The clinician explained that pseudophakia is the medical diagnosis of lens implantation post-cataract. The clinician explained that most cataracts develop in people over age 55 and that the Veteran’s cataracts occurred during the time usually associated with the normal aging of the lens. Finally, the clinician explained that hyperopia, astigmatism, and presbyopia are refractive errors post-cataract surgery which are not pathological in nature. The clinician also concluded that the Veteran’s right eye melanoma is less likely than not related to any injuries incurred during the cave-in. The clinician explained that based on a 2019 American Academy of Ophthalmology study, while it is not clear why melanomas develop, known risk factors include exposure to natural or artificial sunlight over long periods of time, having light-colored eyes, older age, Caucasian descent, certain inherited skin conditions, abnormal skin pigmentation of the eyelids and increased pigmentation of the uvea, and having a mole in the eye or on the eye’s surface. The clinician stated that the only factor regarding loss of vision to the Veteran’s right eye was the choroidal melanoma and that injury is not a known risk factor for the loss of vision. Accordingly, the Board concludes that the Veteran’s left and right eye disorders are less likely than not related to service. The Board finds the December 2019 and October 2020 clinicians’ opinions to be of great probative value as they are supported by rationales based on a review of the record and medical literature. There is no competent evidence of a link between the Veteran’s in-service eye strain or snow blindness to his left or right eye disorders current during the period on appeal. Further, there is no evidence, and the Veteran did not contend, that eye strain or snow blindness were superimposed diseases or injuries resulting in additional disability to any refractive errors. Indeed, at separation, the examiner indicated by omission that snow blindness would not result in disability. In addition, the examiners found that the Veteran’s diagnosed right and left eye disorders, including blepharitis, cataracts, pseudophakia, hyperopia, astigmatism, and presbyopia were all unrelated to service. With respect to right eye melanoma and the Veteran’s right eye removal, the evidence does not show that melanoma was caused by service. Although the December 2019 clinician noted that studies of the association between ultraviolet light and uveal melanoma have yielded mixed results, the examiner nevertheless concluded that the Veteran’s melanoma is less likely than not related to a single episode of corneal sunburn. Likewise, the October 2020 examiner concluded the same which was supported by medical literature. While the May 2008 private physician attributed the Veteran’s right eye loss of vision to a vehicle accident in service, the opinion was not supported by any rationale or explanation. In addition, VA treatment records show the Veteran’s right eye removal was due to melanoma, which was not discussed by the physician. Moreover, melanoma has not been found to be caused by service. (Continued on the next page)   Hence, after reviewing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that service connection for left and right eye disorders is warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. Gilbert, 1 Vet. App. at 55; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. K. R. LAFFITTE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Vashaw, 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.