Citation Nr: 21014137 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 12-27 111A DATE: March 11, 2021 REMANDED Entitlement to an initial compensable rating for left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia is remanded. Entitlement to service connection, to include on a secondary basis, for any eye disorder other than the already-service connected left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1977 to February 2010. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2015, the Veteran testified at a hearing before the undersigned. In a July 2017 decision, the Board denied both eye issue appeals. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court) and the Court granted a Joint Motion for Partial Remand (JMPR) in December 2018. Thereafter, an August 2019 Board decision remanded the matters for further development. There has not been substantial compliance with the remand directives and the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). The Board’s August 2019 decision also remanded the issues of entitlement to service connection for an allergy to diphenyl guanidine as used in medical gloves and entitlement to an increased rating for anxiety disorder to allow the RO to properly certify these appeals to the Board for further review. The Veteran was afforded hearing as to these issues in March 2020, which was conducted by a different Veterans Law Judge. As such, these issues are not before the Board at this time and will be adjudicated in a separate Board decision. 1. Entitlement to an initial compensable rating for left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia is remanded. The Board’s August 2019 remand directed the RO to obtain: (1) a complete set of optometric and ophthalmological treatment records from Walter Reed National Military Medical Center (hereinafter “Walter Reed”) and Kimbrough Army Medical Center (hereinafter “Kimbrough”) from 2003 to the present, to include records of inpatient and/or outpatient eye surgery performed at either medical facility; (2) VA treatment records from July 2019 to the present; (3) all eye-related records stored in Vista Imaging; and (4) outstanding private treatment records, to include those from Dr. J. T., the Veteran’s family optometrist. The Board finds that there has not been substantial compliance with its August 2019 remand directives to obtain outstanding treatment records. While the record reflects that medical treatment records were obtained from Walter Reed from 2010 to the present, records from 2003 to 2009 are not in the Veteran’s claims file. Further, a December 2019 medical records request reject notice indicates that any additional records from Walter Reed should be obtained “via the traditional process,” as those records are non-private. To date, VA has not attempted to obtain these outstanding treatment records. As to the Kimbrough medical treatment records, it appears that this request is still pending, following November 2019 and December 2019 requests for 2003 to 2019 treatment records. Regarding any VA records stored in Vista Imaging, VA has not made a request for these records to be uploaded to the Veteran’s claims file. As to the Veteran’s private treatment records from Dr. J. T., the record does not reflect a complete set of the Veteran’s treatment records, but instead, only records from 2015 and 2019. As such, a remand is required to obtain the identified outstanding treatment records in compliance with the Board’s August 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to service connection, to include on a secondary basis, for any eye disorder other than the already-service connected left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia is remanded. The Board’s August 2019 remand directed the RO to afford the Veteran a new VA examination to assess the current severity of his service-connected left eye disability, as well as to obtain a medical opinion as to the nature and etiology of any other eye diagnoses made during the pendency of the Veteran’s claim, to include whether such diagnoses are directly related to service or caused or aggravated by a service-connected disability. The VA examiner was to offer an opinion as to each eye impairment listed by the Veteran in his June 2019 correspondence and identified by Dr. J. T. in his March 2015 private examination report. Review of the November 2020 VA examination does not reflect compliance with the Board’s August 2019 remand directives. Specifically, the VA examiner’s opinion only addresses the diagnoses of meibomian gland dysfunction, dry eye syndrome, and basement membrane dystrophy, and his rationale as to why service-connection is not warranted is conclusory in nature and lacks adequate rationale. The examiner merely states “I do not believe [these diagnoses] are related to the service-connected condition and are of random etiology.” The VA examiner also failed to address the remaining eye diagnoses of record made during the Veteran’s claim, to include those made by private examiners Dr. J. T. and Dr. L. O. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). For this reason, the matter is remanded to obtain an addendum VA medical opinion. The matters are REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all VA and private treatment records for the Veteran not already associated with the file, to specifically include: (1) treatment records from Walter Reed National Military Medical Center from 2003 to the present; (2) treatment records from Kimbrough Army Medical Center from 2003 to the present; (3) all eye-related treatment records stored in Vista Imaging; and (4) a complete set of private treatment records from Dr. J. T., in compliance with the Board’s August 2019 remand directives. Copies of any outstanding VA and private treatment records should be added to the Veteran's electronic claims file. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran’s claims file. 2. Thereafter, obtain an addendum opinion from an appropriate clinician regarding (i) the etiology of any diagnosed eye disability made during the pendency of the Veteran’s claim other than the already service-connected left eye pseudophakia, and; (ii) the nature and severity of the manifestations specific to the service-connected left eye pseudophakia. Copies of all pertinent records must be made accessible to the designated professional for review. Following the review of the claims file, the medical opinion provider is then requested to respond to the following: (a) Identify all diagnosed disabilities, other than the already service-connected left eye pseudophakia. (b) Is at least as likely as not (a 50 percent probability or greater) that any eye disability specifically diagnosed in (a) had its onset in service or is otherwise directly related to service? (c) Is at least as likely as not (a 50 percent probability or greater) that any eye disability specifically diagnosed in (a) is proximately due to or caused by his service-connected left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia? (d) Is at least as likely as not (a 50 percent probability or greater) that any eye disability specifically diagnosed in (a) underwent any incremental increase in disability, regardless of its permanence, due to the Veteran’s service-connected left eye pseudophakia (postoperative residuals of cataract surgery), anisometropia, cystoid macular edema, epiretinal membrane, macropsia, and metamorphopsia? (e) Specifically identify all manifestations of the service-connected left eye pseudophakia that are not attributed to any other eye diagnoses identified on current examination. In rendering the requested opinions, the examiner should consider, and discuss as necessary: (1) the Veteran’s service treatment records, which reflect a 2006 in-service diagnosis of meibomian gland dysfunction; (2) all eye diagnoses made by Dr. J. T. during the March 2015 private eye examination; (3) all eye diagnoses made by Dr. J. T. during the May 2019 private eye examination; and (4) all eye diagnoses made by Dr. L. O. during the July 2019 private eye examination. If the requested opinions cannot be provided without a new examination, one should be scheduled. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Houle, 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.