Citation Nr: 21022803 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 15-26 606 DATE: April 19, 2021 ORDER Entitlement to service connection for a left eye disability is granted. FINDING OF FACT A left eye disability is etiologically related to the Veteran’s active service. CONCLUSION OF LAW The criteria for service connection for a left eye disability have been met. 38 U.S.C. §§ 1110, 1154, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active naval service from November 1967 to November 1971, including combat service in the Republic of Vietnam. His awards and decorations include the Combat Action Ribbon and Purple Heart Medal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the Veteran’s claims file. In May 2019 and September 2020, this issue was remanded to the RO for further development. The appeal has now been returned to the Board for further appellate action. Service Connection – Left Eye Disability The Veteran maintains that his left eye disability is as a result of an injury incurred during active duty service. The Veteran has been diagnosed with optic atrophy of the left eye, which causes a reduction in visual acuity and visual field restriction. He has also been diagnosed with various other conditions of the left eye, including: dermatochalasis, corneal opacity, corneal arcus, blepharitis, dry eye syndrome, and cataracts. In addition, as noted on the Veteran’s enlistment examination, the Veteran identified that he experienced refractive error of the left eye, a developmental condition distinct from the presently identified left eye disabilities. See October 2019 and 2020, VA Examination Reports. The Veteran equates his left eye disability of optic atrophy to a head injury received during combat. More specifically, the Veteran has explained that while serving in the Republic of Vietnam as a medic, he incurred an injury to the left side of his face while treating a patient in the field amidst being fired upon. Another service-member who was covering him incurred a shrapnel injury, so the Veteran proceeded to treat two patients until rescue helicopters came to assist. Once loaded into the helicopter, it was noticed that the left side of the Veteran’s face was torn open and his left ear drum was bleeding. He was admitted to the hospital and later reported to a VA examiner that he experienced tunneling of his left eye vision after the incident. The Board notes that the combat presumption has been considered in connection with the Veteran’s claim as the Veteran honorably served in combat in the Republic of Vietnam and is in receipt of numerous decorations commemorating such service, including the Combat Action Ribbon and Purple Heart Medal. See DD 214. Under the combat presumption, where the evidence shows that a veteran engaged in combat with the enemy, his or her lay reports will be sufficient to establish the occurrence of an event or injury during combat as long as such reports are consistent with the circumstances, conditions, or hardships of such service. This is true even if there is no official record of the reported incident, unless there is clear and convincing evidence to the contrary. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). A review of the Veteran’s service treatment records reveals that his vision in the left eye was noted as normal upon enlistment. See April 1967, Enlistment Examination. Treatment records from February 1969 and July 1971 show fluctuating vision acuity of the left eye. In February 1969, it is noted at 20/25 and after the Veteran’s combat service, the July 1971 record shows slight decrease in left eye vision acuity of 25/20. There are also two reports of blurred vision, one recorded in December 1967 and the second in March 1970. The November 1971 separation examination noted that the Veteran’s vision was normal, with the exception of defective distant vision in the right eye of 20/60, corrected to 20/20 vision with lenses. The Board is mindful that the decades of time between the Veteran’s separation from service and initial diagnosis is a factor which may be considered as weighing against the claim. However, although a lack of documented treatment is probative, it cannot serve as the sole basis for finding that a present disability is not related to an in-service injury. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In this regard, the Veteran clarified in his hearing before the Board that he did not experience any visual problems in his left eye for a period of time, but came to find out about the nerve damage to his eye after seeking routine treatment. The records reflect that the Veteran began treatment by private eye specialists in 2008, at which time he was diagnosed with optic atrophy. Those treatment records indicate that he was asymptomatic. A January 2009 treatment record reports that the duration of the disability was unknown as the Veteran remained asymptomatic. Another private treatment record from April 2009 again relates that the disability was relatively asymptomatic and also notes that the etiology of it was unknown. The Veteran asserts that during those early treatments, his physicians repeatedly questioned him about any prior head trauma or injury to the eye to ascertain the origin of the optic atrophy, relating that it was the physicians’ opinions that his disability arose from such an injury. The only head-related injury that the Veteran has ever sustained is as described above from his experience in combat. The October 2019 VA examination report cited to peer reviewed medical literature which discusses the connection between trauma and optic neuropathy/atrophy. The examiner did not find signs of traumatic optic atrophy in the Veteran’s left eye disability, and accordingly, stated that a connection to the Veteran’s combat injury could not be made without resorting to mere speculation. An explanation concerning the time passed since the traumatic event and whether such signs of traumatic optic atrophy would be present was not discussed. The October 2020 VA examiner provided a negative nexus opinion but failed to address with particularity the Veteran’s in-service injury and whether the extent of trauma that he underwent to the left side of the head (although not reported or claimed to be a traumatic brain injury) could be related to later discovered optic. nerve damage. The examiner premised his opinion upon the reports within the service treatment records rather than also considering the Veteran’s reported injury which was not fully depicted within the records. A medical opinion is inadequate if the examiner’s rationale fails to account for pertinent evidence, to include competent lay statements describing symptoms of the disability at issue and the incurrence of an injury. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (noting that “lay evidence is one type of evidence that must be considered, if submitted, when a veteran’s claim seeks disability benefits”). Based upon the foregoing, the Board finds that the Veteran’s reports of his private physicians’ findings, the private medical treatment records, the VA examination reports, the injury in service, the varied reports of left eye vision incidents in service, equally weigh both for and against the claim of service-connection for a left eye disability. Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for a left eye disability is warranted. 38 U.S.C. § 5107 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Sutherell, 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.