Citation Nr: 21015336 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 18-33 901 DATE: March 17, 2021 REMANDED Entitlement to service connection for a left eye disability is remanded. REASONS FOR REMAND The Veteran had active service from December 1958 to September 1962. In January 2021, the Veteran appeared and provided testimony at a hearing before the undersigned Veterans Law Judge (VLJ). The Veteran seeks service connection for a macular hole in his left eye, which he asserts resulted from a head injury sustained in service. His VA treatment records confirm that he has a current diagnosis of a left eye macular hole. He also testified before the Board in January 2021 that a provider had told him the hole was likely related to a blow to the head. The Veteran further testified to two in-service incidents wherein he contends he sustained severe blows to his head. The Veteran has not been afforded a VA examination to determine the nature and etiology of the left eye disability on appeal. Significantly, the Board finds that VA’s duty to assist by providing the Veteran with a VA examination to determine the nature and etiology for the disability has been triggered in this case, especially in light of his testimony that a medical provider linked his left eye disability to the types of injuries that he has reported occurred in service. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). As such, a VA examination to determine the nature and etiology of the Veteran’s left eye disability is needed before the Board can decide this claim. Further, in light of the Veteran’s testimony that a private optometrist has linked his left eye disability to a head injury, as well as the fact that these treatment records have not been obtained, the Board finds that attempts should be made to obtain them, as they could contain information which could help substantiate this appeal. Updated VA treatment records should also be associated with the claims file. Accordingly, this matter is REMANDED for the following action: 1. Obtain VA treatment records from August 2017 through the present. 2. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for the identified his left eye macular hole. Make two requests for all authorized records from each provider for all records which have not yet been obtained and associated with the claims file, unless it is clear after the first request that a second request would be futile. 3. After Remand directives “1” and “2,” above have been completed, schedule the Veteran for a VA examination to determine the etiology of his left eye macular hole. The entire claims file, including any electronic records, must be reviewed by the examiner in conjunction with the examination. The examiner is asked to opine as to the following: Is it at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s left eye macular hole had its onset in service or is otherwise related to service, to include as due to the blows to the head that the Veteran asserts he sustained in service? The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If the Veteran’s reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a VA medical examination may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Davidoski, 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.