Citation Nr: 21027709 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-35 135A DATE: May 6, 2021 REMANDED Entitlement to service connection for degenerative disease of the cervical spine with upper extremity pain (claimed as a right shoulder disability) is remanded. Entitlement to service connection for residuals of a left eye injury is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1983 to September 1998. These matters are on appeal to the Board of Veterans' Appeals (Board) from an August 2013 rating decision. A hearing was held by the undersigned Veterans Law Judge in February 2021. Entitlement to service connection for degenerative disease of the cervical spine with upper extremity pain The Veteran contends that his currently diagnosed degenerative disease of the cervical spine is related to the right shoulder pain he has experienced since service. In his hearing, the Veteran clarified that his claimed right shoulder disability is more appropriately framed as degenerative disease of the cervical spine with right shoulder pain, as he contends his spine is the cause of his shoulder pain. He explained that he sought treatment for right shoulder pain in service and after, but x-rays returned normal. Finally, an x-ray of the cervical spine was conducted several years post-service, revealing degenerative disc disease. The Veteran contended that the cervical spine disability was likely due to participation in ruck marches with heavy equipment in the infantry. In his service treatment records (STRs), the Veteran noted shoulder pain as of January 1998; however, the January 1998 record refers to left shoulder pain for one month and the assessment was bursitis. He listed painful joints on his separation examination. A clinical record reflects pain in shoulder area, and "r/o bursitis" and "eval'd on sick call" was written. The Veteran contends that a shoulder x-ray was conducted prior to separation from service. However, there is only a May 1998 radiologic examination report for the chest. Post-service treatment records at Hampton VAMC reflect multiple statements from the Veteran that he has experienced right shoulder pain since 1998, and that he attributes the pain to his military service. Treatment records appear to attribute the Veteran's right shoulder pain to his cervical spine disability. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). As the STRs appear to only reflect treatment for the left shoulder, the Board is unable to reach a determination without a medical opinion on whether the Veteran's cervical spine/right shoulder disability was incurred in or related to service. Thus, remand is required for a medical opinion. Entitlement to service connection for residuals of a left eye injury The Veteran contends that he experiences residuals of an in-service injury to the left eye. The STRs document a scleral laceration to the left eye in 1991. The Veteran received sutures that were removed, and the injury was deemed to be well-healed. In a July 2013 VA examination, the examiner did not diagnose the Veteran with an eye disability. The Veteran explained that he experiences crusting and irritation of the eye; despite these symptoms, the examiner concluded there was no pathology to render a diagnosis. The Veteran has consistently reported symptomatology of the left eye. In October 2011 private treatment records, the Veteran complained of waking up with his eye encrusted shut with purulent material for months. In his VA Form 9, he explained that his left eye tears for no reason and he has seen a civilian doctor since separation. In his hearing, he explained that after his injury, he experienced hard crustacean, irritation, and dry eyes. In his Hampton VAMC records, the Veteran complained of blood in eyes, itching, and watery eyes in August 2017. The ophthalmologist noted the Veteran's 1991 injury and current complaints, and assessed the Veteran with glaucoma suspect, history of recurrent subconjunctival hemorrhage, hypertensive vascular changes, history of corneal injury with tiny corneal scar, and history of chronic conjunctivitis, currently inactive. As the evidence reflects current eye diagnoses, another VA examination must be obtained to determine if the diagnoses or residual symptomatology are related to his in-service eye injury. The matters are REMANDED for the following action: 1. Obtain a VA examination and opinion for the Veteran's degenerative disease of the cervical spine and upper extremity pain. The examiner must first opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's shoulder pain is related to degenerative disease of the cervical spine (diagnosed by x-ray at Hampton VAMC). The examiner must also opine whether it is at least as likely as not that the Veteran's cervical spine disability, shoulder disability, or both are related to service. The examiner is asked to consider and address all relevant evidence of record, to include the Veteran's contentions of shoulder pain in service and that his disability is related to participation in ruck marches carrying heavy equipment in the infantry. 2. The record indicates that the Veteran has seen a civilian doctor for his eye since separation from service. The claims file contains a handful of records from Southside Eye Care; however, attempts must be made to obtain any additional outstanding private treatment records. The Veteran should be provided an opportunity to provide authorization for VA to make such attempts. 3. Then, obtain a VA examination for the Veteran's claimed eye disability. Any and all diagnoses should be identified. As it pertains to the diagnoses reflected in the Hampton VAMC records, the examiner must opine on whether such diagnoses are related to the Veteran's in-service eye injury. Additionally, the examiner must review the Veteran's reported symptomatology of record and opine on whether such symptoms are residuals of his in-service eye injury, and to what diagnoses they are attributable. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Carroll, 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.