Citation Nr: 21024461 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 16-53 677A DATE: April 22, 2021 REMANDED Entitlement to service connection for bilateral eye disability is remanded. REASONS FOR REMAND The Veteran served in the Army from October 1966 to May 1969, including service in the Republic of Vietnam. The Veteran’s exposure to herbicide agents is presumed. 38 C.F.R. § 3.309(a)(6)(iii). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A hearing transcript is associated with the claims file. In June 2020, the Board remanded the Veteran’s claim. The Board notes that current medical records show treatment for various bilateral eye problems. Given this, the Board has recharacterized the claim more broadly. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he/she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). See also, Brokowsky v. Shinseki, 23 Vet. App. 79, 84 (2009) (generally, the scope of a disability claim includes any disability that may reasonably be encompassed by a veteran's description of the claim, reported symptoms, and the other evidence of record). Entitlement to service connection for bilateral eye disability is remanded. The Veteran contends that his private physician told him that his uveitis is due to an autoimmune disorder and that that autoimmune disorder is due to herbicide exposure. See Hearing Transcript (February 2020). In this regard, the Veteran testified that he started experiencing symptoms of uveitis shortly after service and was diagnosed with uveitis in 1974. Id. To ensure that VA has met its duty to assist, remand is necessary. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the November 2020 VA medical opinion is inadequate as the examiner’s rationale relied on the absence of the now diagnosed bilateral idiopathic pars planitis and bilateral pseudophakia during the Veteran’s service as the basis for the negative opinion. The November 2020 VA examiner opined that the Veteran’s bilateral idiopathic pars planitis and bilateral pseudophakia are not caused by service as it was not diagnosed until after service, including a diagnosis of idiopathic pars planitis in 1974 and pseudophakia in 2010. However, an in-service diagnosis is not required to establish service connection. Cosman v. Principi, 3 Vet. App. 503 (1992); see also 38 C.F.R. § 3.303 (d) (service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). Second, the November 2020 VA medical opinion is inadequate because, although it has a conclusion with supporting data, there is not a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). For instance, the opinion was based on general medical studies, which the examiner referred to without identifying the specific studies. See Bailey v. O’Rourke, 30 Vet. App. 54, 60 (2018). The examiner stated that, There is some information that suggest that pars planitis is autoimmune with a genetic predisposition, but the etiology is unknown. Association has been found with HLA DRB1, HLA DR2, DR15 and D51. It has also been found in other autoimmune conditions such as multiple sclerosis and sarcoidosis. C&P Exam (November 2020). Further, it makes no attempt to explain why these findings support the conclusion in the Veteran’s case. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (doctor’s generic statement that chest trauma can be linked to restrictive lung disease insufficient to satisfy medical evidence of nexus requirement). In fact, when discussing the unidentified medical study, the rationale is devoid of any reference to or discussion of facts specific to the Veteran. The opinion here provides no clear conclusion and no adequate application of the medical studies to the Veteran’s particular circumstances. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (although general medical research may be considered, it cannot be the sole basis for examiner’s conclusion). Third, the November 2020 VA medical opinion did not address additional diagnoses of an eye disability contained in the Veteran’s private treatment records submitted in July 2020 prior to the November 2020 VA examination, including senile nuclear sclerotic cataract, hypertensive retinopathy and posterior vitreous detachment. See Medical Treatment Record - Non-Government Facility (July 2020). Additionally, VA treatment records indicate that optometry consult records were scanned from Dr. L.S. in April 2018 into the VA medical records system (VistA Imaging). See CAPRI (June 2020). However, copies of these records are not associated with the VA treatment records or otherwise with the Veteran’s claims file. On remand, these records should be associated and viewable within the Veteran’s claims file. 38 C.F.R. § 3.159(c); Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). Lastly, while the Veteran has provided forms for his private providers, records from some of them have not been obtained and the Veteran was notified of such. In response in August 2020, he indicated that one of his private providers, Dr. H.I., will respond. See VA 21-0820 Report of General Information (August 2020). Presently, the file does not contain a response from Dr. H.I. On remand, the Veteran should be given another opportunity to private treatment records. The Veteran is reminded that VA’s duty to assist in the development of a claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran should cooperate and assist as requested in the development of the appeal. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2020 to the Present. 2. Obtain copies of the non-VA medical records scanned into the VA medical records system with VistA imaging and associate these with the claims file. In particular, this should include documents identified in his VA treatment records as “OPTOMETRY.” 3. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for eye symptoms to include uveitis since discharge from active service to include Dr. H.I. 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. 4. Thereafter, obtain an addendum opinion from an appropriate physician on the nature and etiology of the Veteran’s bilateral eye disability, to include uveitis, idiopathic pars planitis, pseudophakia, senile nuclear sclerotic cataract, hypertensive retinopathy and posterior vitreous detachment. The examiner must opine whether the Veteran’s eye disability(ies) at least as likely as not (50 percent or greater probability) (a) had its onset in service, or (b) is etiologically related to an in-service injury, event, or disease, including exposure to herbicide agents. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). Note (1): A negative medical opinion may not be predicated solely on the absence of documented findings or complaints in service. Note (2) A negative medical opinion may not be predicated on the fact that the diagnosed eye disability(ies) is not a disease presumptively associated with herbicide exposure per 38 C.F.R. § 3.309(e). Note (3): Reliance on the absence of medical literature supporting nexus without discussing the specific facts of the case renders an opinion inadequate. (Continued on the next page)   Note (4): If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each referenced material utilized. 5. Ensure that the VA medical opinion 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 opinions 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. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin 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.