Citation Nr: 21025377 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 02-09 711 DATE: April 28, 2021 REMANDED Entitlement to service connection for a right eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty for training from June 1979 to August 1979 and on active duty from April 1986 to July 1988. The appeal has a lengthy procedural history. Most recently, in September 2020 the Board remanded the issue for further development. Entitlement to service connection for a right eye disorder The Veteran argues that service connection is warranted for a right eye disorder. He contends that while in service, he fell down a hill during a training exercise and injured his right eye. See VA treatment record dated August 7, 2002. The Veteran’s file has been rebuilt. Available service treatment records show that on examination in November 1978 prior to his initial period of active duty training, his eyes were reported as normal on clinical evaluation. On the associated report of medical history, the Veteran indicated that his health was good, and he denied having or having had any eye trouble. On enlistment examination in March 1986, the examiner marked both ophthalmoscopic and pupils as being normal on clinical evaluation. Ocular mobility was initially marked as abnormal, but this was crossed out and reported as normal. On the associated report of medical history, the Veteran again denied having or having had any eye trouble. The March 2004 Board remand references additional evidence noting that service treatment records did not make any reference to a right eye injury; however, the appellant was treated in January 1987 during service for cycloplegia, and a VA neurological examination in April 1989 reported that the right eye had an enlarged pupil with ptosis secondary to an eye injury in childhood. Private neurological records show that the Veteran sustained an injury post-service in January 1998 after being struck on the head. At that time, it was noted he had unequal pupils because of a previous eye injury and surgery on the right eye. A January 2000 record indicates that “on one occasion the right eye became in[f]ected when the headache” was severe on the right side. A March 2000 record notes a past medical history of anisocoria which he has had since sustaining right eye trauma as a child. The Veteran reported that a foreign body was thrown into his right eye and the injury required surgery. A March 2001 record notes a history of baseline anisocoria on the right related to eye trauma. A May 2001 psychiatric evaluation indicates that in 1998, the Veteran suffered an injury to the right occipital-parietal area. His right eye socket did not close all the way and is irritated when he awakens. In June 2018, the Veteran underwent an eye examination for VA purposes. Diagnoses were cataracts both eyes; glaucoma suspect; and probable macular hole. Pupils were 6 mm on the right and 4 mm on the left. There were areas of atrophy in the right iris. The examiner stated that the Veteran did not return for follow-up and the glaucoma diagnosis was not confirmed. In March 2019, a VA physician reviewed the records and opined that there was a better than 50 percent probability that the large dilated right pupil (anisocoria) and right eye blunt trauma in childhood requiring eye surgery existed prior to his period of active service. The examiner noted that the findings on recent examination of right eye anisocoria and right iris atrophy and cup to disc ratio greater on the right were consistent with a history of childhood right eye blunt trauma. Pursuant to the previous remand, additional opinion was obtained in September 2020. At this time, the VA examiner stated that the Veteran clearly and unmistakably had a right eye disability that existed prior to service but she was unable to make other statements without resort to speculation and she would defer to the eye doctor who performed the June 2018 examination. A veteran is presumed sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.§ 1111; 38 C.F.R. § 3.304(b). The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff’d 749 F.3d 1370 (Fed. Cir. 2014). A right eye disorder was not noted on enlistment examination. Considering the evidence of record, the Board finds that the presumption of soundness is for application. See 38 C.F.R. § 3.304(b). There is a two-pronged test for consideration in determining whether the presumption of soundness has been rebutted. First, VA must show by clear and unmistakable (obvious or manifest) evidence that the disease or injury existed prior to service. Second, VA must show by clear and unmistakable evidence that the preexisting disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). On review, there is clear and unmistakable evidence that a right eye disorder, namely anisocoria, preexisted service. Specifically, the VA examiner stated that the objective findings on recent examination were consistent with a history of childhood right eye blunt trauma resulting in a large permanent dilated right pupil. This is consistent with the private treatment records and the Veteran’s reports. There is not, however, clear and unmistakable evidence that this preexisting disorder was not aggravated by service. The Veteran reported an in-service right eye injury and he is competent to report this information. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Further, service treatment records reportedly show treatment for cycloplegia in 1987. The Board observes that “cycloplegia” is defined as paralysis of the ciliary muscle resulting in loss of accommodation. It is usually accompanied by dilatation of the pupil. Millodot: Dictionary of Optometry and Visual Science, 7th edition. (2009); retrieved from https://medical-dictionary.thefreedictionary.com/cycloplegia The presumption of soundness is not rebutted and thus, the in-service element of service connection is met. Notwithstanding, the Veteran must still demonstrate a current disability and a nexus between the current disability and the injury or disease in service. Horn v. Shinseki, 25 Vet. App. 231, 233 (2012). The record contains evidence of current right eye disability and injury in service, and an indication that they may be related. The Board finds that a VA opinion is necessary to address the nexus element. See 38 C.F.R. § 3.159(c)(4). The matter is REMANDED for the following action: 1. Obtain an opinion from a VA clinician with expertise in optometry and/or ophthalmology. An in-person examination is not necessary unless deemed so by the examiner. Based on review of the file, the examiner should answer the following questions: (a.) Does the Veteran have any right eye disorder, to include anisocoria and cataract, that is at least as likely as not related to active service? For purposes of this opinion, please accept as fact that the Veteran suffered a right eye injury during service and was treated for cycloplegia. The impact, if any, of the post-service right eye socket injury should also be considered. (b.) If the answer to (a.) is negative, is it at least as likely as not that any right eye disorder is caused or aggravated beyond its natural progression by the service-connected posttraumatic headaches? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Carsten, 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.