Citation Nr: 21022349 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 17-54 089 DATE: April 15, 2021 REMANDED Entitlement to service connection for an eye disorder, to include as due to herbicide agent exposure and/or secondary to service-connected diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1968 to March 1970, with service in Vietnam. The Veteran is in receipt of the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. The record was held open for 60 days for the Veteran to submit additional information, but none was received. Entitlement to service connection for an eye disorder is remanded. The Veteran contends that his eye disorder, horseshoe tears of the retinas without detachment, are due to Agent Orange exposure and/or his diabetes mellitus. The Board finds that remand is warranted to obtain medical records and adequate addendum opinions. First, remand is required to attempt to obtain private medical records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). At the 2020 Board hearing, the Veteran stated that he had been seeing a private physician, Dr. MD, since 2010 for regular checkups of his eye disorders. Of record is a summary of procedures, medications, and relevant diagnoses from Dr. MD. No treatment records are associated with the claims file and no attempts have been made to obtain these records. Accordingly, this must be done on remand. Second, remand is required to obtain adequate addendum opinions. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). An October 2016 VA examination and opinion were obtained. The examiner opined that the horseshoe tears of the right and left retina are less likely as not caused by or a result of the Veteran’s diabetes mellitus. The examiner noted that although tractional retinal detachment can occur in advanced stages of the common complication of diabetes known as diabetic retinopathy, there was no evidence of diabetic retinopathy. Although this opinion appears adequate, if additional records are obtained on remand, an addendum should be provided. Additionally, the examiner did not address if the Veteran’s diabetes mellitus aggravated the retinal tears or if the tears are caused by herbicide agent exposure. Accordingly, an addendum opinion must be obtained. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for eye symptoms and treatment, to include Dr. MD, the Veteran’s treating eye provider. Make two requests for the authorized records from all identified sources unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from July 2015 to the Present. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s horseshoe tears of the bilateral retinas. The clinician must opine on: (a) Whether the eye disorders are etiologically related to active duty, to include herbicide agent exposure, despite the fact that these disorders are not on the presumptive disease list. (b) Whether the eye disorders are at least as likely as not proximately due to service-connected diabetes mellitus. (c) Whether the eye disorders are at least as likely as not aggravated beyond their natural progression by service-connected diabetes mellitus. 4. Ensure that the opinions obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M., 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.