Citation Nr: 21022152 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-15 035 DATE: April 14, 2021 REMANDED Entitlement to service connection for a bilateral eye disability, to include as secondary to service-connected hypertension, is remanded. Entitlement to a compensable rating for hypertension is remanded. REASONS FOR REMAND The Veteran had qualifying service from August 1990 to July 1994. In October 2018, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. In a March 2019 Decision, the Board, in pertinent part, remanded both issues herein. For the reasons discussed below, the Board finds that the agency of original jurisdiction (AOJ) did not substantially comply with the March 2019 Board directives, such that further medical development is still required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a bilateral eye disability In its March 2019 Decision, the Board found the pertinent VA opinion in August 2017 to be inadequate because the examiner only addressed the theory of secondary service connection and failed to address the theory of direct service connection. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Additionally, the Board notes that the August 2017 VA opinion is further inadequate because the examiner: (a) failed to provide rationale to support the conclusion; (b) only considered the etiology of the dry eye symptoms instead of all diagnosed eye conditions of record; and (c) failed to address the Veteran’s contentions. See August 2017 VA eye conditions examination (diagnosed dry eye syndrome, right nasal pinguecula, and low tear breakup time [TBUT] bilaterally; the Veteran contended that, during service, he was exposed to paint chips getting into his eyes); December 13, 2019, Houston VAMC record (the Veteran reported an injury history of paint chips in the right eye 25 years ago; the provider diagnosed mild and symptomatic pinguecula bilaterally, symptomatic pannus in the left eye, not visually significant [NVS] cataracts bilaterally, and refractive error of presbyopia bilaterally); Barr, supra. Upon remand, the AOJ afforded the Veteran a pertinent opinion in December 2020, in which the examiner found that the Veteran did not have any eye condition other than mild dry eyes, which was less likely than not directly related to service or secondary to service-connected hypertension. Similar to the August 2017 examiner, the December 2020 examiner failed to address the several other eye diagnoses of record, failed to address the Veteran’s contention regarding paint chips, and failed to provide rationale to support the conclusion. Barr, supra; Stegall, supra. As such, the Board must remand so the AOJ can obtain an adequate etiological opinion that: (a) addresses all eye diagnoses of record, including, but not limited to, (i) dry eye syndrome (see August 2017 VA eye conditions examination), (ii) right nasal pinguecula (see August 2017 VA eye conditions examination), (iii) TBUT bilaterally (see August 2017 VA eye conditions examination), (iv) mild and symptomatic pinguecula bilaterally (see December 13, 2019, Houston VAMC record), (v) symptomatic pannus in the left eye (see December 13, 2019, Houston VAMC record), (vi) NVS cataracts bilaterally (see December 13, 2019, Houston VAMC record), and (vii) refractive error of presbyopia bilaterally (see December 13, 2019, Houston VAMC record); (b) addresses the Veteran’s contention of in-service eye injury involving paint chips in his eyes, which he has consistently reported (see August 2017 VA eye conditions examination; see also December 13, 2019, Houston VAMC record) and which may be consistent with the circumstances of his service as a mechanic (see DD Form 214); and (c) contains adequate rationale to support the conclusions. 2. Entitlement to a compensable rating for hypertension During the October 2018 Board hearing, the Veteran testified that he takes daily medication for hypertension and the dosage was increased from 10 milligrams to 40 milligrams. In its March 2019 Decision, the Board found that a new examination was warranted due to the Veteran’s contention of worsening since the pertinent VA examination in January 2015. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Upon remand, the AOJ afforded the Veteran a pertinent examination in October 2019. The examiner, in pertinent part, diagnosed hypertension, but also listed current hypertension symptoms as headaches and nosebleeds. Further, the October 2019 examiner noted that the functional impact of the hypertension was that the Veteran cannot work when he gets headaches due to blurred vision. However, in the remarks section of the examination, the examiner indicated that there was no change in the service-connected diagnosis and no additional diagnoses had been rendered. The Veteran’s hypertension disability is currently rated only under diagnostic code (DC) 7101, which contemplates hypertensive vascular disease but does not specifically contemplate headaches or nosebleeds. See January 2021 Codesheet; 38 C.F.R. § 4.104, DC 7101. Further, the Veteran has not yet been awarded any separate ratings under different diagnostic codes for additional hypertension manifestations outside of the scope of DC 7101, including, but not limited to headaches and nosebleeds. See January 2021 Codesheet. Crucially, in increased ratings claims, VA has a duty to maximize benefits, including for secondary conditions or separate ratings under different diagnostic codes. Morgan v. Wilkie, 31 Vet. App. 162, 167-68 (2019). However, the October 2019 examiner did not provide rationale for why he attributed the Veteran’s headaches and nosebleeds to the service-connected hypertension (as opposed to any of the Veteran’s other service-connected and nonservice-connected diagnoses), which is an especially important distinction because the AOJ and the Board have already denied a claim for entitlement to service connection for headaches (see December 2017 Rating Decision; see also March 2019 Board Decision). Barr, supra. Further, headaches and nosebleeds may indicate periods of hypertensive crisis, which the October 2019 examiner failed to address. Barr, supra. As such, the Board must remand so the AOJ can obtain medical clarification as to whether the Veteran’s headaches and nosebleeds: (a) are at least as likely as not etiologically related to his service-connected hypertension (as opposed to any of the Veteran’s other service-connected and nonservice-connected diagnoses); and (b) indicate periods of hypertensive crisis. The matters are REMANDED for the following action: 1. Regarding the bilateral eyes claim, obtain an adequate etiological opinion that: (a) addresses all eye diagnoses of record, including, but not limited to, (i) dry eye syndrome (see August 2017 VA eye conditions examination), (ii) right nasal pinguecula (see August 2017 VA eye conditions examination), (iii) TBUT bilaterally (see August 2017 VA eye conditions examination), (iv) mild and symptomatic pinguecula bilaterally (see December 13, 2019, Houston VAMC record), (v) symptomatic pannus in the left eye (see December 13, 2019, Houston VAMC record), (vi) NVS cataracts bilaterally (see December 13, 2019, Houston VAMC record), and (vii) refractive error of presbyopia bilaterally (see December 13, 2019, Houston VAMC record); (b) addresses the Veteran’s contention of in-service eye injury involving paint chips in his eyes, which he has consistently reported (see August 2017 VA eye conditions examination; see also December 13, 2019, Houston VAMC record) and which may be consistent with the circumstances of his service as a mechanic (see DD Form 214); and (c) contains adequate rationale to support the conclusions. The examiner is advised the that August 2017 and December 2020 VA opinions are inadequate because the examiners: (a) failed to address all eye diagnoses of record; (b) failed to address the Veteran’s contention regarding paint chips in the eyes during service; and (c) failed to provide rationale to support the conclusion. Due to COVID-19, the Board defers to the examiner’s discretion to determine whether in-person examination is required to render the requested information. 2. Regarding the hypertension claim, obtain medical clarification as to whether the Veteran’s headaches and nosebleeds: (a) are at least as likely as not etiologically related to his service-connected hypertension (as opposed to any of the Veteran’s other service-connected and nonservice-connected diagnoses); and (b) indicate periods of hypertensive crisis. See October 2019 VA hypertension examination (the examiner, in pertinent part, diagnosed hypertension, listed current hypertension symptoms as headaches and nosebleeds, and noted that the functional impact of the hypertension was that the Veteran cannot work when he gets headaches due to blurred vision, but, in the remarks section, indicated that there was no change in the service-connected diagnosis and no additional diagnoses had been rendered; however, the examiner did not provide rationale for why he attributed the Veteran’s headaches and nosebleeds to the service-connected hypertension [as opposed to any of the Veteran’s other service-connected and nonservice-connected diagnoses], which is an especially important distinction because the AOJ and the Board have already denied a claim for entitlement to service connection for headaches [see December 2017 Rating Decision; see also March 2019 Board Decision]). Due to COVID-19, the Board defers to the examiner’s discretion to determine whether in-person examination is required to render the requested information. 3. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Daus, 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.