Citation Nr: 21022124 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 18-21 703 DATE: April 14, 2021 REMANDED Entitlement to service connection for residuals of a left eye injury is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1974 to July 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for chronic angle glaucoma (claimed as left eye condition) because the evidence submitted was not new and material. In January 2021, the Veteran testified at a tele-hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In light of the Veteran’s clarifying hearing testimony, the Board has recharacterized the Veteran’s claim of service connection for glaucoma as a claim of service connection for residuals of a left eye injury. As the Veteran is claiming a separate disability from glaucoma, new and material evidence is not necessary in this case. In light of the remand below, no prejudice to the Veteran has resulted from the Board’s recharacterization of the issue. Bernard v. Brown, 4 Vet. App. 384 (1993) (holding that before the Board may address a matter that has not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument, an opportunity to submit such evidence or argument, and an opportunity to address the question at a hearing, and whether the claimant has been prejudiced by any denials of those opportunities). Entitlement to service connection for residuals of a left eye injury is remanded. The Veteran contends that he injured his left eye with a screwdriver during active duty and that additional debris had to be removed from his eye. See January 2021 Transcript of Hearing, pages 5-6. Service treatment records (STRs) dated in July 1975 noted the Veteran’s complaints of sensitivity to light and blurred vision focusing on distant objects. STRs dated in September 1975 indicated that the Veteran had been treated for trauma to his right eye with a screwdriver. It was noted that he received sutures to his right lower lid. The assessment was corneal abrasion. A January 1976 entry in the Veteran’s STRs noted the Veteran’s complaints of a metallic foreign body in his left cornea, which was removed. VA treatment records obtained in connection with the Veteran’s claim noted a history of trichiasis of the left upper lid. See 2016-2018 VA treatment records. The Veteran was afforded a VA examination in August 2018. The examiner noted the following diagnoses: no residuals from corneal abrasion of the right eye/lower lid laceration of the right eye, faint small opacity in the left eye, not in visual axis, and bilateral open angle glaucoma. The Veteran reported a left eye injury involving a corneal abrasion and lid damage from a screwdriver while on active duty in 1975. He reported irregular growth of eyelash along the lid that irritated his left eye subsequent to the injury. The Veteran reported that he needed to have the eyelash pulled monthly and that his left eye was slower to open. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran’s left eye. The examiner opined, The Veteran’s complaint of persistent trichiasis (lash irritating cornea/conjunctiva) OS [left eye] is not related to his history of having to have a metallic foreign body removed from his OS while on active duty in 1976 (Please note: date at upper right corner of consult sheet to ophthalmology in veteran’s STR appears to be “1978” but the treating ophthalmologist’s signature date = “1976” (Veteran reports being active duty 1974-76). Veteran’s screwdriver injury involving his lower lid occurred in 1975 to his OD [right eye] (not his OS). Veteran’s past treatment of trichiasis involved his left upper lid. Faint, small opacity from foreign body removal 1976 OS is unrelated to his history of trichiasis OS and does not affect his vision. (It is not in the visual axis/line of sight.) The Board finds that the VA examination is inadequate. In that regard, although the examiner determined that the Veteran’s left eye trichiasis was unrelated to an in-service left eye foreign body removal, the examiner failed to provide an adequate rationale for his opinion. As such, remand is warranted for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, at the January 2021 Board hearing, the Veteran identified VA treatment records that had not been associated with the claims file. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Given the Veteran’s assertions, a remand is also warranted to enable the RO to undertake the appropriate efforts to obtain the outstanding VA records. Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (holding that VA’s duty to assist in obtaining records is triggered if the claimant identifies VA medical records; the claimant is not required to show that VA records are relevant). Accordingly, the matter is REMANDED for the following action: 1. Undertake the necessary efforts to obtain VA medical records which have not already been associated with the claims file from the West Palm Beach VA, or any other VA medical facility that may have treated the Veteran, from the mid-1980’s through present. 2. Afford the Veteran a VA examination to determine the nature and etiology of his current residuals of a left eye injury. Access to the Veteran’s electronic VA claims file must be made available to the examiner in connection with the examination. The examiner is to identify all current eye pathology. After examination of the Veteran and review of the claims file, the examiner should provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that any current left eye disability identified on examination had its inception during the Veteran’s active duty or is otherwise causally related to an in-service disease or injury, to include a left eye metallic foreign body removal in January 1976? A complete explanation must be provided for any opinion offered. In providing the requested opinion, the examiner should reference any relevant evidence of record, to include the Veteran’s service treatment records, VA medical records, and the Veteran’s January 2021 hearing testimony which indicated that he injured his left eye during active duty. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.