Citation Nr: 21025158 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 14-14 627 DATE: April 27, 2021 ORDER Entitlement to service connection, to include on a secondary basis, for myasthenia gravis, is denied. FINDING OF FACT The preponderance of the evidence demonstrates that the Veteran does not have myasthenia gravis which is related to service. CONCLUSION OF LAW The criteria for service connection for myasthenia gravis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2008 to April 2009. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board in July 2018. A transcript of that hearing is of record. The appeal was last remanded in October 2020 for further development. The requested development has been accomplished and the case is ready for adjudication. Entitlement to Service Connection for Myasthenia Gravis is Denied The Veteran contends that he has myasthenia gravis as a result of an in-service fall off his bunk. Alternatively, he contends that the claimed condition is due to or aggravated by his service-connected disorders. The Veteran is service connected for major depressive disorder, chronic progressive external ophthalmoplegia (CPEO), previously rated as exotropia and diplopia, and obstructive sleep apnea. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may additionally be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The Board concludes that the Veteran does not have a current diagnosis of myasthenia gravis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Importantly, the Veteran was granted service connection for exotropia and diplopia in May 2011 (as noted below later this diagnosis was changed to chronic progressive external ophthalmoplegia). Thus, for service connection to be established, it must be found that the claimed disorder, myasthenia gravis, is separate and distinct from that disorder. Here, the evidence weighs against a finding that the Veteran has myasthenia gravis. The claims file includes diagnoses of myasthenia gravis and findings that the Veteran does not have this disorder, taken as a whole, the preponderance of the evidence is against finding that the Veteran has this disorder. Post-service records include a May 2011 VA examination wherein the Veteran was diagnosed with left eye exotropia and presence of diplopia as well as ptosis of the right upper lid. Private treatment notes from Dr. J.C. dated in July 2012, include a report that the Veteran had had myasthenia gravis for four years which could not be diagnosed until this year. Dr. J.C. stated that the Veteran’s symptoms had been present since service and that he believed it was related to service. In January 2013, the Veteran had an informal hearing with a Decision Review Officer. Notes from that discussion reported that the Veteran reported that he had double vision in the left eye. He stated that he fell from a bunk in basic training and went to sick call for his left eye problem but was not really treated for it. At a January 2014 VA examination, it was noted that an April 2012 treatment note the Veteran reported that he fell out of his bunk bed in 2008 with resultant diplopia and blurry vision. The examiner further noted a November 2013 VA treatment record which found ocular myasthenia gravis with negative antibodies. It was noted that the Veteran was treated with CellCept and Mestinon (for myasthenia gravis) to no effect. Higher doses of Prednisone were reported as helping with ptosis but did not help with double vision. A diagnosis of ocular myasthenia was provided. A March 2017 note from neuro-ophthalmologist Dr. K.S. noted that Dr. J.C. diagnosed myasthenia gravis, but that it was unclear what the diagnosis was based on other than clinical findings as antibodies drawn for myasthenia were negative and an EMG was also believed to be negative. It was further noted that while a Tensilon test was not conducted Pyridostigmine, Prednisone and CellCept (medications for the treatment of myasthenia) did not improve the Veteran’s symptoms. The examining neurologist stated that given the collection of findings he believed the most likely diagnoses were chronic progressive external ophthalmoplegia phenotype, bilateral intranuclear ophthalmoplegia, or myasthenia. It was noted that myasthenia was much less likely with the results of an edrophonium test and that CPEO was the most likely diagnosis. Private treatment records dated February 2018 included diagnoses of exotropia and CPEO. In July 2018, the Veteran testified before the undersigned Veterans Law Judge. At his videoconference hearing, the Veteran reported that he was treated for his fall and given crutches, but he was not referred for eye treatment. The Veteran stated that he did not receive further care and that his vision got progressively worse. The Veteran reported that he had chronic vision problems since service. In July 2019, the Veteran’s claims file was sent to an examiner for review in order to determine whether myasthenia gravis was related to the Veteran’s service-connected PTSD. Following review of the record, the examiner determined that it was less likely than not that the Veteran’s myasthenia gravis was caused by his TBI or PTSD. The examiner explained that the medical literature did not support a causative relationship between these diagnoses. The claims file was provided to a neurologist for review in October 2019 in order to obtain an opinion on the nature and etiology of the Veteran’s claimed myasthenia gravis. Following review of the claims file, the examiner concluded that the Veteran had chronic progressive external ophthalmoplegia which was diagnosed as myasthenia in error. The examiner stated that none of the Veteran’s diagnostic tests confirmed myasthenia and that the Veteran was found to have restricted eye movements noted on forced duction testing which was not found in myasthenia gravis and the Veteran did not respond to treatment for myasthenia gravis. The examiner stated, “he does NOT have myasthenia gravis.” The examiner explained that CPEO was unrelated to trauma and would not be affected by such, and if trauma caused his eye movement abnormality, it would not progress. The examiner stated that CPEO was a genetic disorder of the mitochondria and was not caused by head injury or trauma or autoimmune phenomena and the Veteran had this disorder from birth. The examiner further explained that the eye condition originally diagnosed as exotropia and diplopia, was revised to chronic progressive external ophthalmoplegia. A September 2020 examination of the eyes included a diagnosis of chronic progressive external ophthalmoplegia and noted that ptosis was related to such. A January 2020 examination included diagnoses of ptosis and diplopia. The Board finds that the preponderance of the evidence is against service connection. While the Veteran asserts that he has myasthenia gravis, he does not have the medical expertise to diagnose this condition as opposed to other eye conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to describe eye and vision symptoms; however, he lacks the medical training or qualification to diagnose an eye disability, to distinguish it from other eye disabilities or establish its etiology. Id. His opinion therefore cannot provide the requisite nexus and does not refute the medical opinion of record. The Board notes that the Veteran has been diagnosed, on at least two occasions, with myasthenia gravis, however, the overwhelming medical evidence weighs against this finding. As noted above, numerous other physicians have reviewed the diagnosis and noted that testing was negative for myasthenia gravis, and that the Veteran more likely had CPEO. These findings are based upon review of the record, examination of the Veteran, and extensive testing and are therefore probative. In as much as the Veteran has been found to have chronic progressive external ophthalmoplegia, this diagnosis was noted as replacing the Veteran’s diagnoses of exotropia and diplopia. The probative evidence demonstrates that the Veteran’s eye symptoms which he asserts are related to myasthenia gravis are related to disorders which are already service connected. The evidence weighs against a finding that the Veteran has a separate eye disorder, myasthenia gravis, which is related to service or a service-connected disorder. Thus, service connection for myasthenia gravis must be denied. [ KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Slovick, 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.