Citation Nr: 21027315 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-30 310 DATE: May 5, 2021 REMANDED Entitlement to service connection for Sjogren's syndrome with vitreous degeneration and punctate keratitis. REASONS FOR REMAND The Veteran served on active duty from November 1990 to November1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2018. In January 2021, the Board remanded the case in order to provide the Veteran with a supplemental statement of the case, which was accomplished in March 2021. Entitlement to service connection for Sjogren's syndrome with vitreous degeneration and punctate keratitis. The Veteran contends his currently diagnosed Sjogren's syndrome is related to his service, to include exposure to environmental hazards during service in Southwest Asia. As an initial matter, the Board notes that private and VA treatment records reflect a diagnosis of Sjogren's syndrome. However, the Veteran's service records, to include service treatment records, do not reflect service in the Southwest Asia theater of operations during the Persian Gulf War. In this regard, the Veteran's DD-214 reflects he is a recipient of the Overseas Service Ribbon. His record reflects service in Germany from November 1991 to November 1995 but does not reflect any other overseas service. Remand is needed to attempt to verity service in Southwest Asia. The Veteran should be asked to provide details of this service, and the RO should follow-up the service department to confirm any such service. In February 2018, the Veteran underwent a VA Gulf War General Medical Examination, at which time, systemic lupus erythematosus or other immune disorders was assessed. The examiner also conducted a VA examination to determine the nature and etiology of his Sjogren's syndrome. The VA examiner offered an opinion that was specific to whether the Veteran's Sjogren's syndrome was caused by environmental exposure while on active duty during the Persian Gulf War. Specifically, the examiner stated that Sjogren's syndrome is a rheumatic disease with a clear diagnosis, and that the cause of such disorder is uncertain, although some individuals with certain genes may have a higher risk, and thus, such disorder was less likely than not caused by his service in the Gulf War. The Veteran also underwent a VA eye examination in April 2018. At that time, the VA examiner stated, as pertinent, that while there were reports of troop exposure to various toxins that may induce autoimmune disorders such as Sjogren's, there is no definitive evidence to substantiate that exposure to toxins during the Persian Gulf War conflict cause autoimmune disorders. As mentioned, the currently record reflects no service in Southwest Asia. If this remand results in evidence of service Southwest Asia, the VA examiner's opinion is inadequate as it required definitive evidence of a medical link. The ultimate question of fact in this case is not whether causality is definitive. The examiner's burden of proof is demanding a level of certainty inconsistent with VA's lower standard of proof (Veterans benefits are authorized so long as the evidence for and against that question is in "approximate balance"). See Wise v. Shinseki 26 Vet. App. 517, 531-32 (2014). Moreover, the opinion does not address whether the condition is related to service even if he did not have service in Southwest Asia. Therefore, a remand is necessary in order to obtain an addendum opinion regarding the etiology of the Veteran's Sjogren's syndrome. The matters are REMANDED for the following action: 1. Contact the Veteran and ask that he provide details concerning his service in Southwest Asia, including all dates, units, and location(s) in the Southwest Asia theater of operations, which is defined as Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 2. Contact the National Personnel Records Center (NPRC), Joint Service Records Center (JSSRC) or any other appropriate entity, and request verification of service in Southwest Asia theater of operations during the Persian Gulf War. Any response should be documented in the claims file. 3. Forward the Veteran's file to the February 2018 VA examiner for a medical opinion addressing the nature and etiology of his claimed Sjogren's syndrome. If the February 2018 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The examiner is asked to opine whether it is at least as likely as not that his Sjogren's syndrome had its onset in, or is otherwise related to his service. (a.) If service in Southwest Asia is not established, the examiner should address whether there is a relation to service regardless of whether he had service in Southwest Asia during the Persian Gulf War. (Continued on the next page) (b.) If service in Southwest Asis established, the examiner should assume that he was exposed to toxic substances, which might have included oil well fires, diesel exhaust, paints, pesticides, depleted uranium, depleted uranium, infectious agents, investigational drugs and vaccines, and indigenous diseases, and also immunizations Corey Bosely Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.