Citation Nr: 21024648 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 13-10 798 DATE: April 23, 2021 ORDER Entitlement to service connection for an eye disability is denied. FINDING OF FACT The competent and probative evidence of record demonstrates that the Veteran’s currently diagnosed eye disabilities are not related to his military service, to include as due to in-service exposure to herbicide agents, or secondary to his service-connected hypertension. CONCLUSION OF LAW The criteria for service connection for an eye disability are not met. 38 U.S.C. §§ 105, 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1965 to February 1985, to include service in Vietnam. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2008 rating decision. The Board remanded the issue on appeal in June 2015, October 2017, June 2020, and January 2021 for further development. The agency of original jurisdiction (AOJ) has substantially complied with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for an eye disability is denied. The Veteran claims entitlement to service connection for an eye disability. He contends that the conditions began while he was serving in the Army in Vietnam and that his symptoms began in 1969. See May 2017 VA examination report. He contends that, as he left the Army, he was told that his eye pressure was high-normal, but he was not given any medication. The record indicates that the Veteran requested glaucoma testing in June 1994 due to deteriorating vision. He contends that every year he had the glaucoma checked it was always high-normal, and then in 2007, when he changed to a new eye physician, his measurements showed that he had glaucoma. He believes that he had glaucoma as he was leaving the Army and in subsequent examinations at Walter Reed Army Hospital. See June 1994 private treatment records; see also June 2008 VA Form 21-4138. The Veteran also contends that his eye disability is due to herbicide exposure in Vietnam. See September 2011 VA Form 21-4138; see also October 2017 Veteran Statement. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be awarded on a secondary basis for disability which is caused or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310(a). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the central nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era also will be presumed to have been incurred in service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). This presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). There is no question the Veteran had service in-country in Vietnam, and he is therefore presumed to have been exposed to herbicide agents. However, eye disabilities are not among the diseases that are associated with herbicide exposure for purposes of this presumption. 38 C.F.R. § 3.309(e). The Secretary, under the authority of the Agent Orange Act of 1991 and based on the studies by the National Academy of Sciences (NAS), has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. That being said, even if a Veteran is found not entitled to a regulatory presumption of service connection, the claim still must be reviewed to determine whether service connection may be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed Cir. 1994). See, also, McCartt v. West, 12 Vet. App. 164, 167 (1999) (the principles set forth in Combee, which instead concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). Review of the Veteran’s service treatment records indicates no complaints, treatment, or diagnosis of glaucoma. The record indicates that the Veteran was diagnosed with glaucoma in January 2008, he had cataract surgery in his left eye in March 2008, and he had cataract surgery in his right eye in September 2010. See May 2017 Eye Conditions Disability Benefits Questionnaire (DBQ). The Veteran underwent a VA examination in May 2017 resulting in diagnoses of primary open angle glaucoma, bilateral; pseudophakia with posterior capsular opacity, status post cortical age-related cataract, left eye; pseudophakia with posterior capsular opacity, status post posterior subcapsular cataract, right eye; pinguecula, bilateral; dry eye syndrome; and presbyopia. As a result of the examination, the VA examiner opined that, after review of the e-folder, it is at least as likely as not that the Veteran’s condition of primary open angle glaucoma was incurred during his service from September 1968 to February 1985. The examiner explained that the eye exam record on May 24, 1982 noted ocular health to be normal, both eyes. A large cup-to-disc ratio of the optic nerve in both eyes was first noted at an optometry exam on May 9, 1989, and the Veteran was subsequently diagnosed as a glaucoma suspect. Based on the large cup-to-disc ratio finding in 1989, it is at least as likely as not that the Veteran had similar findings while he was in the service, and thus a suspect for glaucoma. The Veteran was diagnosed with primary open angle glaucoma in both eyes on January 1, 2008 and was started on ocular hypotensive eye drops as treatment. This diagnosis was supported by elevated intraocular pressure and optic nerve damage on his previous eye exams. His previous visual field results show early visual field loss in the right eye, consistent with glaucoma. The Veteran has since been treated and followed for the glaucoma every 6-12 months by Dr. T.S.K. The Veteran’s current clinical findings remain consistent with primary open angle glaucoma. Though the May 2017 VA examiner opined that glaucoma and cataracts are related to service, they did not identify an in-service event, and for that reason, an addendum opinion was requested to clarify the opinion and identify an event/injury in service. The August 2017 VA examiner offered an addendum opinion regarding conflicting medical evidence in which they noted that the records indicate the Veteran separated from military service in February 1985, and there are no identifiable injuries or events related to his ocular health noted and/or documented to have occurred during his military service. They noted that the diagnosis of glaucoma was made in 2008, treatment for cataracts was started in 2008, and the time elapsed from the Veteran’s separation from military service to his claimed eye conditions was 23 years. They explained that glaucoma is the result of damage to the optic nerve and that, as this nerve gradually deteriorates, blind spots develop in the visual field. They explained that, for reasons that doctors don’t fully understand, this nerve damage is usually related to increased pressure in the eye. Elevated eye pressure is due to a buildup of a fluid (aqueous humor) that flows throughout the eye. This fluid normally drains into the front of the eye (anterior chamber) through tissue (trabecular meshwork) at the angle where the iris and cornea meet. When fluid is overproduced or the drainage system doesn’t work properly, the fluid can’t flow out at its normal rate and pressure builds up. They noted that glaucoma tends to run in families and, in some people, scientists have identified genes related to high eye pressure and optic nerve damage. The examiner noted that risk factors include having high internal eye pressure (intraocular pressure (IOP)); being over 60; being black or Hispanic; having a family history of the condition; having certain medical conditions such as diabetes, heart disease, high blood pressure, and sickle cell anemia; having certain eye conditions such as nearsightedness; having had an eye injury or certain types of eye surgery; and taking corticosteroid medications, especially eyedrops, for a long time. With respect to cataracts, the August 2017 VA examiner explained that a cataract is a cloudy or opaque area in the normally clear lens of the eye and, depending upon its size and location, it can interfere with normal vision. They explained that most cataracts develop in people over age 55, but they occasionally occur in infants and young children. Usually cataracts develop in both eyes, but one may be worse than the other. The lens is located inside the eye behind the iris, the colored part of the eye, and normally the lens focuses light on the retina, which sends the image through the optic nerve to the brain. However, if the lens is clouded by a cataract, light is scattered so the lens can no longer focus it properly, causing vision problems. The lens is made of mostly proteins and water, and clouding of the lens occurs due to changes in the proteins and lens fibers. Cataracts generally form very slowly, and signs and symptoms of a cataract may include blurred or hazy vision, reduced intensity of colors, increased sensitivity to glare from lights, particularly when driving at night, increased difficulty seeing at night, and change in the eye’s refractive error. The examiner explained that there is no treatment to prevent or slow cataract progression. In age-related cataracts, changes in vision can be very gradual. Some people may not initially recognize the visual changes. However, as cataracts worsen, vision symptoms increase. Most cataracts are due to age-related changes in the lens of the eye that cause it to become cloudy or opaque. The examiner concluded that, based on the evidence reviewed and the known risk factors for these conditions, it is their opinion that the eye conditions of glaucoma and cataract are less likely than not related to any in-service event or injury. The record includes a VA medical opinion provided in July 2019 in which the VA examiner stated that the Veteran’s primary open angle glaucoma was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that medical records document the claimant was diagnosed with primary open angle glaucoma on January 1, 2008. The examiner further explained that glaucoma is the result of damage to the optic nerve; as this nerve gradually deteriorates, blind spots develop in the visual field. For reasons that doctors don’t fully understand, this nerve damage is usually related to increased pressure in the eye. The Veteran separated from service in 1984. Records dated May 9, 1989 indicate the Veteran was suspicious for glaucoma due to abnormal large cup/disc (C/D) ratio of the optic nerve, and records dated June 24, 1991 also designate the Veteran as a glaucoma suspect due to large C/D. The VA examiner further explained that refractive error does not have any relation with glaucoma, and any changes of the optic nerve raise suspicion for glaucoma but absent any other factors would not be significant enough to support a diagnosis of glaucoma. The examiner explained that the documented observations were made after the Veteran separate from service and that, in their opinion, suspicions that occurred several years after separation are not enough to nexus condition with service. See July 2019 VA examination report. The July 2019 VA examiner also addressed the Veteran’s pseudophakia with posterior capsular opacity status post cortical age-related cataract, left eye; and pseudophakia with posterior capsular opacity status post posterior subcapsular cataract, right eye, and opined that both were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that medical records document the Veteran underwent cataract surgery in June 2009 and was further diagnosed with pseudophakia on May 13, 2017. The examiner explained that a cataract is a cloudy or opaque area in the normally clear lens of the eye and that depending upon its size and location it can interfere with normal vision. The VA examiner further explained that most cataracts develop in people over age 55, and that the Veteran was in his mid-60s when he underwent cataract surgery. For cataracts that interfere greatly with vision, doctors usually remove the lens of the eye. Sometimes the patient gets a new transplanted lens. The VA examiner explained that the medical diagnosis of lens implantation post cataract is pseudophakia. The examiner explained that the Veteran separated from service in 1984, and records are silent on any eye condition while in service, therefore the claimed condition is less likely than not related to service. With respect to the Veteran’s diagnosed pinguecula and dry eye syndrome, the July 2019 VA examiner opined that the conditions were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that medical records document the Veteran was diagnosed with pinguecula and dry eye syndrome on May 13, 2017, the Veteran separated from service in 1984, and the records are silent on any eye condition while in service; therefore, the claimed condition is less likely than not related to service. With respect to the Veteran’s diagnosed presbyopia, the July 2019 VA examiner opined that the condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that presbyopia usually occurs beginning at around age 40, when people experience blurred near vision when reading or working at the computer. The examiner explained that presbyopia is caused by an age-related process and is generally believed to stem from a gradual thickening and loss of flexibility of the natural lens inside the eye. The VA examiner further explained that these age-related changes occur within the proteins in the lens, making the lens harder and less elastic over time. Age-related changes also take place in the muscle fibers surrounding the lens and, with less elasticity, the eye has a harder time focusing up close. The VA examiner noted that the condition is developmental and reiterated that it is less likely than not related to the Veteran’s service. The record includes a VA medical opinion provided in July 2020 regarding whether the Veteran’s eye disabilities were caused by his service-connected hypertension. The July 2020 VA examiner stated that they could determine a baseline level of severity and that the April 7, 2001 exam documents full visual field, cupping of bilateral optic nerves, and IOP of 22 with diagnosis of glaucoma suspect in both eyes (OU). The examiner noted that the current severity was greater than the baseline and that the Veteran’s eye disability was at least as likely as not aggravated beyond its natural progression by his service-connected hypertension. The VA examiner explained that on January 21, 2008, the vision field of the right eye is showing an early nasal step and an IOP of 26 documenting mild progression in the right eye (OD). The examiner further explained that there is insufficient medical evidence to document progression in the left eye (OS) as a visual field could not be obtained for the left eye on the date of that exam due to advanced age-related cataract OS. A second VA medical opinion offered by the July 2020 VA medical examiner stated that the baseline level of severity could be determined as the April 7, 2001 exam documents full visual field, cupping of bilateral optic nerves and IOP of 22 with diagnosis of glaucoma suspect OU; this is the earliest accurate documentation that they could locate in the service treatment records. The VA examiner noted that the current severity is greater than the baseline, but that it was not at least as likely as not aggravated beyond its natural progression by the Veteran’s service-connected hypertension. The examiner explained that the visual field of the right eye shows mild nasal step on March 27, 2008 documenting mild progression from 2001; however, this is the natural progression of early glaucoma without intervention. There is no evidence in the medical records to support that the eye disability to include glaucoma were worsened by the hypertension and there is insufficient evidence in the medical literature to support a causal effect between hypertension and open angle glaucoma. The July 2020 VA examiner also offered an opinion that the Veteran’s glaucoma was more likely than not an age-related or hereditary ocular condition, and the nuclear cataracts were age-related and natural progression in time; neither were related to the herbicide exposure. They stated that they see no other evidence or ocular diagnosis in the medical record that would more likely than not be related to herbicide exposure. See July 2020 VA examination report. The July 2020 VA examiner was requested to provide clarification of their report and, in October 2020, the examiner clarified that it was their opinion that it is not at least as likely as not that the Veteran’s diagnosed eye disabilities, to include glaucoma, were caused by his service-connected hypertension and that it is not at least as likely as not that the Veteran’s eye disabilities of glaucoma were caused by his in-service herbicide exposure or diabetes. They explained that the glaucoma is diagnosed as open angle and is most likely due to hereditary or developmental causes; diabetes tends to be associated with neovascular-type glaucoma. See October 2020 VA examination report. Pursuant to the January 2021 remand, a VA medical opinion was obtained in January 2021 stating that, based upon a review of the Veteran’s VA e-folder, the VA examiner noted the Veteran has been diagnosed with primary open angle glaucoma, bilateral; pseudophakia with posterior capsular opacity, status post cortical age-related cataract, left eye; pseudophakia with posterior capsular opacity, status post posterior subcapsular cataract, right eye; pinguecula, bilateral; dry eye syndrome; and presbyopia. The January 2021 VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness and explained that a review of medical literature and medical records fails to provide any correlation between herbicide exposure and the diagnosed eye disabilities, specifically glaucoma, cataracts, pseudophakia, pinguecula, dry eye syndrome, and presbyopia. The VA examiner further explained that it is less likely than not that these diagnoses are causally related to the Veteran’s active service, to include exposure to herbicide agents, and the diagnoses of cataracts, pseudophakia, and presbyopia are most likely due to natural aging progression rather than herbicidal exposure. Additionally, the glaucoma is most likely hereditary or age-related and the pinguecula is most likely due to UV exposure rather than herbicide exposure. See January 2021 VA examination report. The January 2021 VA examiner opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected hypertension and explained that there is conflicting evidence in the medical literature to support any relationship between hypertension and glaucoma and there is insufficient evidence in the medical record to support a correlation; the cataracts, pseudophakia, and presbyopia are most likely age-related and less likely than not due to hypertension, and the pinguecula is mostly likely due to UV and environmental irritants and less likely than not due to hypertension. The January 2021 VA examiner stated that they could not determine a baseline level of severity of the Veteran’s eye disability based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by hypertension as the medical evidence is not sufficient to support a determination of a baseline level of severity. The VA examiner further opined that, regardless of an established baseline, the Veteran’s eye disability is not at least as likely as not aggravated beyond its natural progression by his service-connected hypertension. The examiner explained that it is less likely as not (a 50 percent probability or greater) that the Veteran’s service-connected hypertension aggravated the Veteran’s diagnosed glaucoma, cataracts, pseudophakia, pinguecula, dry eye syndrome, and presbyopia, as there is conflicting evidence in the medical literature to support any relationship between hypertension aggravating glaucoma and there is insufficient evidence in the medical record to support a correlation. The VA examiner further explained that there is some evidence to support the opposite, that systemic hypotension aggravates glaucoma, which the Veteran does not have. The examiner explained that the cataracts, pseudophakia, and presbyopia are most likely aggravated by age and less likely than not due to hypertension, and the pinguecula is most likely aggravated by UV and environmental irritants and less likely than not due to hypertension. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection. The January 2021 VA opinions are the most probative evidence of record. The VA ophthalmologist is qualified through education, training, and experience to offer medical diagnoses, statements, or opinions. Moreover, the opinions reflect consideration of the Veteran’s history, to include his treatment for his eye disability, and his statements concerning the onset of his visual problems. The examiner offered the opinions based on a review of the Veteran’s VA e-folder and medical literature. The VA examiner supported the opinions with thorough rationale and noted other factors that were more likely to have caused or aggravated the Veteran’s eye disabilities, including age, hereditary factors, UV and environmental irritants. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (“[A] medical opinion... must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions.”). The Board acknowledges the Veteran’s contentions that his eye disability is related to his military service, to include as due to his in-service exposure to herbicide agents, or secondary to his service-connected hypertension. While he is competent to report his in-service symptoms, he is not competent to opine on complex medical questions such as the etiology of his current eye diagnoses. Specifically, where the determinative issue is one of medical causation as presented here, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). The question of causation or aggravation of an eye disability involves a medical subject of an internal physical process extending beyond the immediate observable cause-and-effect relationship. As such, the determination of the etiology of his eye disability requires a specialized understanding of the medical nature and pathology of the disorder(s), which he has not been shown to have. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s lay statements are not considered competent on that issue. Moreover, the Board finds that the Veteran may not prevail under the presumptive provisions governing service connection for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Although such diseases include disabilities of the central nervous system, service connection would not be warranted unless the eye disability manifested to a compensable degree within a year of the Veteran’s release from active service in December 1970, or if he exhibited a continuity of symptomatology since that time. In this case, there is no competent evidence of record which demonstrates that an eye disability manifested to a compensable degree within one year from discharge, and there is no evidence demonstrating a continuity of symptoms following service. In fact, the record shows that the Veteran was not diagnosed with any eye disability until many years after service. In conclusion, the Board finds that the claim for service connection for an eye disability must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as no competent and probative evidence supports the required elements of his claims, that doctrine is not applicable. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Fulmer, 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.