Citation Nr: 21020934 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-15 045A DATE: April 8, 2021 ORDER Entitlement to service connection for bradycardia, claimed as an "irregular heartbeat," is granted. Entitlement to service connection for a vision disorder, claimed as "blurred vision," is denied. REMANDED Entitlement to service connection for a vestibular disorder, claimed as "dizziness," is remanded. Entitlement to service connection for a left hamstring disorder is remanded. Entitlement to service connection for right hamstring disorder is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s service-connected polycystic kidney disease with hypertension caused his bradycardia. 2. The Veteran’s astigmatism and presbyopia are congenital in nature. CONCLUSIONS OF LAW 1. The criteria for service connection for bradycardia, claimed as an "irregular heartbeat," have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a vision disorder, claimed as "blurred vision," have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1986 to December 1989, from November 1990 to April 1991, and from March 2003 to June 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). Issue 1: Entitlement to service connection for a cardiac disorder, claimed as an "irregular heartbeat" Secondary Service Connection Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Merits The Veteran claimed service connection for an "irregular heartbeat" in November 2011. The AOJ denied service connection for an irregular heartbeat in March 2012, and the Veteran appealed the denial. As the appeal was pending, multiple medical professionals have diagnosed him with bradycardia. For example, the July 2020 VA examiner diagnosed the Veteran with "moderate bradycardia with a heart rate of 47 [based] on a recent EKG." This satisfies the first prong of a secondary service connection claim for this disorder. VA has service connected the Veteran's polycystic kidney disease with hypertension. This satisfies the second prong of a secondary service connection claim for this disorder. This appeal turns on the third prong of a secondary service connection claim – medical nexus. In this regard, the Board first considered this appeal in October 2018. The Board ordered a VA examination to determine the nature and etiology of the claimed disorder. VA, in turn, examined the Veteran in December 2018. The appeal returned to the Board in May 2020. The Board, upon reviewing the December 2018 examination report, found: Regarding the Veteran’s heart condition, the examiner provided a diagnosis of bradycardia. He then provided an opinion regarding an irregular heartbeat only, stating there was no connection to service since the Veteran was not currently diagnosed with the condition. The examiner further provided a general description of the Veteran’s kidney disease with hypertension, to include a potential link to various heart symptomology. He provided no opinion, however, regarding any connection between the Veteran’s bradycardia and his kidney disease with hypertension, specifically. He also did not address any potential connection between the Veteran’s heart condition and his acquired psychiatric disorder. After review, the Board notes it is unclear why the examiner discounted the Veteran’s reports of … heart problems since service. In addition, as described above, above, the rationale[] supporting the examiner’s opinion[] regarding any connection between the Veteran’s condition[] and his service-connected psychiatric disorder and kidney disease with hypertension are inadequate or entirely absent. The Board, based on the above, remanded the issue for a new VA examination. VA, in turn, examined the Veteran in July 2020. The examiner opined on both direct and secondary service connection. In reviewing these opinions, the Board will cite two excerpts from the secondary opinions. The first states: The veteran first noticed symptoms in 2003 when he was in Iraq, according to the records he had symptoms of headache, dizziness, and an irregular heartbeat. At that time Veteran went to medical and he was diagnosed with systolic hypertension. It was discovered during the work-up that the veteran had polycystic kidney disease which is the cause of the essential hypertension. Diagnosed with polycystic kidney disease. As well as laboratory analysis. The veteran’s potassium and magnesium, very important electrolytes to the heart’s electrical activity were not recorded at that time in the medical records. They were subsequently reported in the progress note of 1/18/2017 and there were no electrolyte issues contributing to his heart condition. All of the veteran’s symptoms at that time were due to kidney disease with hypertension. The second states: With regards to the kidney disease with hypertension, the kidney disease could be associated with electrolyte abnormalities such as hypermagnesemia, hyperkalemia, also abnormalities in calcium and phosphorus metabolism that could cause an electrical irregularity to the heart or bradycardia, but there is no evidence of this in the medical record. In attempting to understand these opinions, the Board has not identified the January 18, 2017 VA treatment record the July 2020 VA examiner cited. However, it has identified a similar March 24, 2017 VA treatment record. This record shows that a VA cardiologist examined the Veteran for treatment purposes on that date. The cardiologist noted that the Veteran's "EKG shows ventricular rate 60 beats per minute, sinus bradycardia, left ventricular enlargement by VOLTAGE criteria due to hypertension." The July 2020 VA compensation examiner's opinion appears to focus on the following causal chain: kidney disease leads to electrolyte abnormalities, which in turn, lead to bradycardia. However, it is unclear to what extent the hypertension is involved in this causal chain because the examiner did not explain. Moreover, the Board affords high probative value to the cardiologist's opinion because he specializes in the area of the disability under consideration. Indeed, the March 24, 2017 treatment record shows how the Veteran's primary VA care physician expressly sought out a cardiology consultation for the bradycardia. While the cardiologist did not expressly explain how he concluded that the hypertension caused the bradycardia, the Board is satisfied, given the circumstances, that the Veteran has met the third prong of a secondary service connection claim for this disorder. The Veteran has satisfied all three prongs of a secondary service connection claim for this disorder. Therefore, the Board will grant the appeal. Issue 2: Entitlement to service connection for a vision disorder, claimed as “blurred vision” Direct Service Connection Generally, service connection may be granted for any disability resulting from injury suffered or disease contracted in line of duty, or for aggravation in service of a pre-existing injury or disease. 38 U.S.C. §§ 1110, 1131. Service connection may be established by demonstrating that the disability was first manifested during service and has continued since service to the present time or by showing that a disability which pre-existed service was aggravated during service. Service connection may be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. Merits The Veteran claimed service connection for "blurred vision" in November 2011. The AOJ denied service connection for blurred vision in March 2012, and the Veteran appealed the denial. The Board first considered this appeal in October 2018. The Board ordered a VA examination to determine the nature and etiology of the claimed disorder. VA, in turn, examined the Veteran in December 2018. The appeal returned to the Board in May 2020. The Board, upon reviewing the December 2018 examination report, found: Regarding the Veteran’s blurred vision, the examiner stated there was no pathology to render a diagnosis. At this juncture, the Board notes that the U.S. Court of Appeals for the Federal Circuit recently held that symptomatology may constitute a disability for service connection purposes where the evidence shows the symptomatology causes functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). The Board further notes the Veteran has asserted his blurred vision is secondary to headaches, and the examiner did not address this contention. After review, the Board notes it is unclear why the examiner discounted the Veteran’s reports of … blurred vision … since service. In addition, as described above, the rationale[] supporting the examiner’s opinion[] regarding any connection between the Veteran’s condition[] and his service-connected psychiatric disorder and kidney disease with hypertension are inadequate or entirely absent. The Board, based on the above, remanded the issue for a new VA examination. VA, in turn, examined the Veteran in September 2020. The examiner opined that the "claimant has no ocular pathology other than for astigmatism and presbyopia which are errors of refraction unrelated to any in service event, disease or trauma." As background, presbyopia is a visual condition that becomes apparent especially in middle age and in which loss of elasticity of the lens of the eye causes defective accommodation, and inability to focus sharply for near vision. McNeely v. Principi, 3 Vet. App. 357, 364 (1992). Also, Dorland’s Illustrated Medical Dictionary defines astigmatism as an unequal curvature of the refractive surfaces of the eyes. 28th ed, 151 (1994). VA regulations provide that refractive errors of the eyes, as present here, are not diseases or injuries within in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Because the Veteran does not have a vision disorder other than refractive errors, the Board finds the Veteran does not have a current vision disability. As such, he fails the first prong of either a direct or secondary service connection claim, and the Board must deny his appeal. REASONS FOR REMAND Remand is warranted for the remaining appellate issues. Entitlement to service connection for a vestibular disorder, claimed as "dizziness" The Veteran claimed service connection for "blurred vision" in November 2011. The AOJ denied service connection for blurred vision in March 2012, and the Veteran appealed the denial. The Board first considered this appeal in October 2018. The Board ordered a VA examination to determine the nature and etiology of the claimed disorder. VA, in turn, examined the Veteran in December 2018. The appeal returned to the Board in May 2020. The Board, upon reviewing the December 2018 examination report, found: Regarding the Veteran’s dizziness, the examiner diagnosed benign positional vertigo. He noted the Veteran’s in-service complaints of dizziness but opined the Veteran’s vertigo was unrelated to service on the basis that he was not diagnosed with vertigo during service. Regarding any relation between the Veteran’s vertigo and his psychiatric disorder and/or kidney disease with hypertension, the examiner stated these conditions did not cause vertigo, but provided no medical explanation. After review, the Board notes it is unclear why the examiner discounted the Veteran’s reports of … dizziness … since service. In addition, as described above, the rationale[] supporting the examiner’s opinion[] regarding any connection between the Veteran’s condition[] and his service-connected psychiatric disorder and kidney disease with hypertension are inadequate or entirely absent. The Board, based on the above, remanded the issue for a new VA examination. VA, in turn, examined the Veteran in July 2020. The examiner stated that the Veteran did not then have, nor had he ever had, an "ear or peripheral vestibular condition." This finding contradicts the December 2018 VA examiner. Moreover, the September 2020 examiner opined that "the claimed dizziness is merely a symptom of the veteran’s underlying medical and mental conditions. There is no current objective evidence noted on my exam to warrant a diagnosis at this time." The September 2020 examination report, because of its unexplained findings and contradiction of the December 2018 examination report, necessitates remand. The Board needs to determine the etiology of the benign positional vertigo and to further inquire as to the etiology opinion the September 2020 examiner offered. Therefore, remand is warranted for an addendum opinion. Entitlement to service connection for a left hamstring disorder Entitlement to service connection for right hamstring disorder The Veteran claimed service connection for "hamstring, bilateral legs" in November 2011. The AOJ denied service connection for "pulled two hamstrings in right leg" and "pulled two hamstrings in left leg" in March 2012, and the Veteran appealed the denials. The Board first considered this appeal in October 2018. The Board ordered a VA examination to determine the nature and etiology of the claimed disorders. VA, in turn, examined the Veteran in December 2018. The appeal returned to the Board in May 2020. The Board, upon reviewing the December 2018 examination report, found: Regarding the Veteran’s hamstrings, as noted by the Board in its October 2018 remand, the Veteran suffered a hamstring injury in March 2003 during service. The VA examiner provided a diagnosis of bilateral hamstring strain. He noted the evidence of a bilateral hamstring injury during service, and the Veteran’s reports of continuous problems with his hamstrings ever since. He then opined the condition was unrelated to service on the basis that there was no medical evidence showing continuity of symptomatology since service. After review, the Board notes it is unclear why the examiner discounted the Veteran’s reports of … hamstring … problems since service. The Board, based on the above, remanded the issue for a new VA examination. VA, in turn, examined the Veteran in July 2020. The examiner opined: The Veterans Bilateral Hamstring Sprain is less likely than not is less likely than not incurred or caused by hamstring injury in service. The veteran recalls playing football in March 2003 and in which while running injured both his hamstrings. He also said he went to sick call because of this issue. However, I find no record that he was placed in sick call for bilateral hamstring injury nor did I find any record of limitations because of this injury. There are multiple records for this Veteran in 2003 and 2004, however there is only one mention of bilateral hamstring injury that “has improved” in 2004. There is no other mention of any issue with the bilateral hamstrings. Of note there is mention of a left effusion that was recorded by the physician in Iraq in 2003. On subsequent physical exams for back injuries and multiple physical exams in regard to his hypertension and kidney disease there is no mention of lower extremity weakness or pain as it relates to posterior thigh or hamstring problems. Also in 2004 because of back problems he had limitations on walking, going up stairs, lifting and repetitive motions but no restrictions when he came to in the hamstring lower leg injury. In fact he was approved for thigh stretches hamstring stretches etc. So the medical records do not support a chronic injury of bilateral hamstrings while in service. The Board finds this opinion inadequate. The question the Board needs to answer is whether the Veteran's in-service injury caused his current disability, not whether he had a "chronic injury of bilateral hamstrings" in service. Therefore, remand is warranted for an addendum opinion. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Obtain an addendum opinion from the medical professional who examined the Veteran in July 2020 for his claimed vestibular order. That professional, or someone of comparable qualifications if that professional is unavailable, should opine on: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's benign positional vertigo, as diagnosed by the December 2018 VA examiner, began during, or was otherwise caused by, service? Why or why not? In providing his or her opinion, the examiner should address the service medical records showing in-service complaints of dizziness, and the Veteran’s statements that his dizziness has persisted ever since service. b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected acquired psychiatric disorder CAUSED his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? c) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected acquired psychiatric disorder AGGRAVATES his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? d) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected polycystic kidney disorder with hypertension CAUSED his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? e) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected polycystic kidney disorder with hypertension AGGRAVATES his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? f) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected headaches CAUSED his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? g) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected headaches AGGRAVATE his benign positional vertigo, as diagnosed by the December 2018 VA examiner? Why or why not? h) What did you mean when you stated "the claimed dizziness is merely a symptom of the veteran’s underlying medical and mental conditions" in September 2020? i) To which "underlying medical and mental conditions" would the "claimed dizziness" be a symptom? If you are referring to any of the Veteran's service-connected disabilities, expressly identify the disabilities to which you referred. The examiner must provide a rationale, supported by medical explanation, for any opinion offered. 3. Obtain an addendum opinion from the medical professional who examined the Veteran in July 2020 for his claimed hamstring residual disabilities. That professional, or someone of comparable qualifications if that professional is unavailable, should opine on: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s left hamstring strain, as diagnosed by the December 2018 VA examiner, began during, or was otherwise caused by, service, to include his March 2003 in-service football injury? Why or why not? b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s right hamstring strain, as diagnosed by the December 2018 VA examiner, began during, or was otherwise caused by, service, to include his March 2003 in-service football injury? Why or why not? In providing his or her opinion, the examiner should address the service medical records showing a March 2003 in-service hamstring injury, and the Veteran’s statements that he has had hamstring pain and other problems ever since service. The examiner must provide a rationale, supported by medical explanation, for any opinion offered. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Sopko, 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.