Citation Nr: 21029306 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 17-17 283 DATE: May 13, 2021 ORDER Entitlement to a rating in excess of 80 percent for bilateral eye conditions prior to March 26, 2019 is denied. Entitlement to a rating in excess of 90 percent for bilateral eye conditions from March 26, 2019 to August 1, 2019 is denied. Entitlement to a 100 percent rating for bilateral eye conditions from August 1, 2019 is granted. Entitlement to a separate 20 percent rating for bilateral lacrimal gland disorder is granted. REMANDED Entitlement to an increased special monthly compensation (SMC) rating is remanded. FINDINGS OF FACT 1. Prior to March 26, 2019, the Veteran's eye disabilities manifested in central visual acuity of 5/200 or worse (right) and 20/70 (left rounded up because 20/60 is not listed in the rating criteria) and loss of visual field right with contraction of visual field left equivalent to 20/100. 2. For the period from March 26, 2019 to August 1, 2019, the Veteran's eye disabilities manifested in visual acuity of 5/200 or worse (right) and 20/100 (left), and loss of visual field right with contraction of visual field left equivalent to 20/200. 3. Resolving reasonable doubt in the Veteran's favor, he suffered a stroke in August 2019 that reduced his left visual field to less than 5 degrees (evaluated as equivalent to 5/200) as shown in the October 2019 examination. 4. Resolving reasonable doubt in the Veteran's favor, he has bilateral lacrimal gland disorder which results in meibomian gland dysfunction, dry eye, tearing/watering, and blepharitis due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 80 percent for bilateral eye conditions prior to March 26, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.25, 4.3, 4.7, 4.76, 4.77, 4.79, Diagnostic Codes (DCs) 6026, DC 6064, 6080. 2. The criteria for a rating in excess of 90 percent for bilateral eye conditions from March 26, 2019 to August 1, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.25, 4.3, 4.7, 4.76, 4.77, 4.79, DCs 6026, 6064, 6080. 3. The criteria for a 100 percent rating for bilateral eye conditions from August 1, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.25, 4.3, 4.7, 4.76, 4.77, 4.79, DCs 6026, 6064, 6080. 4. The criteria for a separate 20 percent rating for bilateral lacrimal gland disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.25, 4.3, 4.7, 4.76, 4.77, 4.79, DC 6025. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1958 to January 1961. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which continued a 30 percent rating for residuals of a right corneal ulcer with scarring, thinning, and irregular astigmatism with end-stage open angle glaucoma and pseudophakia. An August 2017 rating decision granted entitlement to service connection for left eye visual field constriction, and combined the bilateral eye disabilities for an 80 percent rating effective March 16, 2015 (date of claim). A May 2020 rating decision provided a 90 percent rating for the Veteran's bilateral eye disabilities, effective March 26, 2019, and a 100 percent rating was provided effective October 7, 2019. The Board notes that the front page of the May 2020 rating decision and the notification letter for the May 2020 rating decision erroneously listed the effective date of the 90 percent rating grant as March 26, 2016. However, the rating decision codesheet and the narrative paragraph explaining the increased 90 percent rating noted the correct effective date of March 26, 2019. These issues were previously before the Board in August 2018. The Board remanded for additional VA examination to determine the current severity of the Veteran's eye disabilities. Additionally, the Veteran is in receipt of total disability based on individual unemployability (TDIU) based singularly on his visual impairment, effective March 16, 2015 (date of claim for an increased eye rating). He was awarded special monthly compensation (SMC) k-1 for loss of use of the right eye (light perception only), also effective March 16, 2015. And in an April 2019 rating decision, he was awarded SMC s-1 for one disability rated at 100 percent, and a second disability rated at 60 percent or greater, effective January 17, 2019 (the effective date of the grant of a 100 percent rating for hepatitis C). The Veteran requested a Board videoconference hearing on his March 2017 substantive appeal. However, in March 2018 the Veteran (through his representative) withdrew his request for a Board hearing. 1. Entitlement to a rating in excess of 80 percent for bilateral eye conditions prior to March 26, 2019 is denied. 2. Entitlement to a rating in excess of 90 percent for bilateral eye conditions from March 26, 2019 to August 1, 2019 is denied 3. Entitlement to a 100 percent rating for bilateral eye conditions from August 1, 2019 is granted. 4. Entitlement to a separate 20 percent rating for bilateral lacrimal gland disorder is granted. The Veteran is seeking increased rating for his bilateral eye disorders. The case was returned to the Board with staged ratings of 80 percent prior to March 26, 2019, 90 percent from March 26, 2019, and 100 percent from October 7, 2019. With this decision, the Board will provide the 100 percent rating from August 1, 2019 (unknown August 2019 stroke resulting in additional left visual field impairment), deny a rating in excess of 90 percent from March 26, 2019 to August 1, 2019, and deny a rating in excess of 80 percent prior to March 26, 2019. Additionally, the Board will resolve reasonably doubt in the Veteran's favor and provide a separate 20 percent rating for bilateral lacrimal gland disorder for the entire period on appeal (from March 16, 2015). During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. The Veteran's right eye corneal ulcer residuals with glaucoma and pseudophakia were previously rated under DCs 6077-6029. DC 6029 provides rating for aphakia or dislocation of the crystalline lens. The records have not indicated that the Veteran had aphakia or dislocation of the crystalline lens. He has been repeated noted to have had a corneal graft, glaucoma, and optic nerve damage in his right eye. His bilateral ratings have been provided based on visual acuity (DC 6064) and visual field impairment (DC 6080). DC 6026 addresses optic neuropathy. Under the former criteria, DC 6026 instructed to evaluate based on visual impairment. Under the revised criteria, DC 6026 does not specify how the disability is to be rated. Pursuant to § 4.79, therefore, it is to be evaluated under the General Rating Formula for Diseases of the Eye. The Board notes that the General Rating Formula for Diseases of the Eye instructs to evaluate a condition based on visual impairment or its rating criteria for incapacitating episodes. DC 6013 addresses open-angle glaucoma. Both the former and revised criteria indicate that a minimum 10 percent rating was warranted if continuous medication was required. Under the former criteria, DC 6013 instructed to evaluate pursuant to visual impairment due to open-angle glaucoma. Under the revised criteria, DC 6013 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye. Prior to March 26, 2019 VA treatment records include Humphrey Visual Field testing from August 20, 2012 wherein the Veteran's right eye was "dim overall with slight upper lid shadow," and his left eye was "full." On March 24, 2015, the Veteran reported to VA ophthalmology that his right vision was becoming dimmer, his eye was bloodshot, and he had a "throbbing" pain. He also had intermittent sharp pains, increased flashes, and had been feeling nauseated. His left visual acuity was stable/comfortable. He was assessed with acute pain in blind right eye with no findings except injection. He had recently been taken off of prednisone (steroid), so he was restarted on that with tapering. His left visual acuity was 20/20-2. For the purposes of rating the Veteran's right eye vision loss, where there is no anatomical loss of the eye but there is no light perception, his right visual acuity is considered 5/200 (the worst visual acuity for which there is a listing). Under DC 6064, corrected central visual acuity of 5/200 (right eye) and 20/20 (left eye) warrants a 30 percent rating. On April 3, 2015, the Veteran reported increased flashes and floaters in his left eye for the past 4 weeks. On April 27, 2015, the Veteran's corrected left distance vision was 20/40-2. On May 19, 2015, the Veteran participated in a fee-basis VA eye examination. He was diagnosed with bilateral blepharitis, right status-post corneal graft, bilateral pseudophakia with mild PCO (posterior capsular opacification) left eye, right glaucoma, right blindness secondary to optic disc disease and glaucoma, and visual field defect of the left eye secondary to an unknown cause, "most likely testing reliability errors." He was also noted to have bilateral diabetic retinopathy, left chronic vitreal floaters, and "glaucoma suspect left eye based on visual field only." His corrected distance vision was 5/200 right and 20/40 or better left. His corrected near vision was 5/200 right and 20/40 or better left. He did not have a difference equal to 2 or more lines on the Snellen test type chart between distance and near corrected vision. He did not have diplopia. He had right vision limited to no more than light perception. He had a right corneal irregularity resulting in severe irregular astigmatism; however, he did not wear contacts because correcting the irregularity would not improve his vision due to the severity of his optic nerve disease. On external eye examination, the Veteran had bilateral blepharitis and MGD (meibomian gland dysfunction) of the eyelids. He had a right corneal graft. Dry eye syndrome was not noted on examination. He had bilateral peripheral iridotomy and posterior intraocular lenses, the left lens had patchy PCO. His right optic disc had 0.95 cupping, no superior or inferior rim, and 1+ pallor. His left optic disc was normal. His right vitreous contained an old hemorrhage, and his left vitreous contained floaters. Visual field testing was completed; however, it was Humphrey 30-2 threshold testing. Goldmann perimeter and kinetic threshold 120 full testing options were not available. The Humphrey visual field testing showed bilateral loss of temporal half, nasal half, inferior half, and superior half of the Veteran's vision. He also had a scotoma affecting at least 14 of his visual field for both eyes, and a centrally located scotoma of the right. He did not have statutory blindness based on visual field loss (visual field diameter of 20 degrees or less in the better eye). The examiner marked that the Veteran's bilateral blepharitis was a "disorder of the lacrimal apparatus" and that it did not cause scarring or disfigurement. Under the "corneal conditions" section, the examiner selected that the Veteran had right eye corneal transplant without "pain, glare, or photophobia per patient complaint." His central visual impairment was partially due to corneal irregularity; the other partial cause was end-stage glaucoma in the right eye. Regarding his cataract surgery, he had bilateral postoperative cataracts with replacement lens (pseudophakia) without aphakia or dislocation of the crystalline lens. His cataracts did not decrease his visual acuity or cause other visual impairment. Regarding his glaucoma, the Veteran had "mixed mechanism glaucoma, unknown etiology, possible NAION (non-arteritic anterior ischemic optic neuropathy) related, possible malignant hypertension secondary to traumatic injury." His right glaucoma was treated with continuous medication (Cosopt). His glaucoma was the partial cause of his decreased visual acuity/visual impairment. His glaucoma did not cause scarring or disfigurement. He had not had any incapacitating episodes of an eye condition in the past 12 months (under the former definition). The examiner provided a negative left eye nexus opinion. Under DC 6080, bilateral loss of the temporal half of visual field warrants a 30 percent rating. Bilateral loss of nasal half warrants a 10 percent rating. Bilateral loss of inferior half warrants a 30 percent rating and bilateral loss of superior half warrants a 10 percent rating. Combing these ratings under 38 C.F.R. § 4.25 (combined rating table) equates to a 60 percent rating for visual field impairment. Under DC 6064, corrected central visual acuity of 5/200 (right eye) and 20/40 (left eye) warrants a 30 percent rating. Combining the 30 percent rating for visual acuity and 60 percent rating for visual field impairment under 38 C.F.R. § 4.25 equals a 70 percent rating. On September 3, 2015, the Veteran underwent YAG laser capsulotomy of the left eye, to improve clouding of the membrane around the Veteran's implanted lens (from cataract surgery). This laser treatment was to improve his PCO. Prior to laser treatment, the Veteran's visual acuity was 20/60 left. He reported a slow painless progressive decline in his left eye vision, and intermittent blurriness which improved some with blinking. Under DC 6064, vision of 5/200 (right) and 20/70 (left rounded up because 20/60 is not listed in the rating criteria) warrants a 50 percent rating for central visual acuity. Combining this 50 percent rating with the 60 percent rating for visual field impairment shown in the VA examination equals an 80 percent rating. By December 10, 2015, the Veteran's vision was described as "very little light perception" in the right eye and corrected distance vision of 20/20-1 left eye. Under DC 6064, corrected central visual acuity of 5/200 (right eye) and 20/20 (left eye) warrants a 30 percent rating. By September 27, 2016, the Veteran's vision was described as "barely" light perception of the right eye and 20/25+ corrected distance vision of the left eye. A February 13, 2017 VA ophthalmology record noted corrected distance vision of 20/50 left eye. Under DC 6064, corrected central visual acuity of 5/200 (right eye) and 20/50 (left eye) warrants a 40 percent rating. On July 13, 2017, the Veteran denied new vision problems. He was found to have end-stage glaucoma of the right eye with light perception only. His corrected left distance vision was 20/25. On August 12, 2017, the Veteran participated in a second fee-basis VA examination. "Sometimes he can see clear[ly] and other times vision is blurry." He has glaucoma in the right eye due to surgery. He also had uncontrolled diabetes. During his last eye examination in July 13, 2017, his right eye was light perception only with end-stage glaucoma and vitreous heme. He was taking Alphagan for his right eye glaucoma. His corrected distance vision was 5/200 or worse (right), and 20/40 or better (left). His corrected near vision was 5/200 or worse (right) and 20/40 or better (left). The examiner selected that the Veteran had a difference equal to 2 or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with near vision being worse. The Board notes that there was no difference listed between his corrected distance and near vision, so the examiner's selection does not correlate to the written findings. Second recordings of the Veteran's corrected distance and near vision of the left eye were 20/40 or better. The examiner noted that the difference between the distance and near vision was due to the list perception of the right eye. He did not have diplopia. On slit lamp evaluation, he had a clear graft with some central haze in his right cornea, and a surgical scar of the left cornea. Both lenses were clear. Internal eye evaluation information was not provided. He had not had any incapacitating episodes in the prior 12 months (under the former regulations). Regarding functional impact of the Veteran's vision, the examiner noted that the Veteran had poor depth perception and "will not drive." The examiner provided a negative secondary service connection opinion regarding the Veteran's left eye disability, noting the Veteran had 20/20 corrected distance and near vision of his left eye. Goldmann perimeter visual field testing was completed in connection with the August 2017 examination. This Board member's reading of the left visual field chart showed remaining visual field of 133 degrees. When divided by the 8 principal meridians, this results in concentric contraction of left visual field with remaining field of 16.625 degrees. Under DC 6080, concentric contraction of visual field with remaining field of 16 to 30 degrees should be evaluated as though the affected eye has central visual acuity of 20/100. The Veteran's right eye visual field test was not included as he had light perception only. This is considered as remaining field of 5 degrees (the lowest available in the rating criteria) which should be evaluated as though the affected eye has central visual acuity of 5/200. Under DC 6064, visual acuity of 5/200 (right) and 20/100 (left) warrants a 60 percent rating. Regarding the Veteran's corrected distance vision, under DC 6064 visual acuity of 5/200 (right) and 20/40 or better (left) warrants a 30 percent rating. Combining a 60 percent rating for visual field concentric contraction with a 30 percent rating for central visual acuity, the 2017 examination showed findings warranting a 70 percent rating under 38 C.F.R. § 4.25 (combined rating table). During the period prior to the 2017 examination, visual field testing using the Goldmann perimeter charts was not available. As such, the 2017 findings will be applied to the period prior to the examination as well. A September 2015 treatment record showed his worst left central visual acuity of 20/60. As noted above, that finding warranted a 50 percent rating under DC 6064. Combining a 50 percent rating for central visual acuity with a 60 percent rating for visual field defect under the combined rating table at 38 C.F.R. § 4.25 shows that a combined 80 percent rating is warranted. An October 18, 2017 VA ophthalmology record showed the Veteran's corrected left distance vision was 20/30. On January 17, 2018, the Veteran felt and suffered trauma to his arms, legs, and head with loss of consciousness for 2 minutes. He was hospitalized for two days. He had a negative head CT. Initially, he was listed as having had a mild concussion due to poor balance due to diabetic polyneuropathy. A January 19, 2018 record noted that a neurology consultation had determined that his "fall [was] due to imbalance related to diabetic polyneuropathy." On March 1, 2018, the Veteran reported to VA ophthalmology that his vision had worsened since last August, although he had not sought any treatment. He stated that "since his fall his vision is better at times than others." He was noted to have had a fall with concussion in January 2018. His corrected distance vision was 20/40 left eye, with a notation that "changing the vertex distance seems to improve the vision." He was given a new prescription for glasses. On April 20, 2018, the Veteran reported to VA ophthalmology that he fell in January and was told he may have had a "light" stroke. His corrected left visual acuity was 20/40. He was to continue Lotemax and Alphagan for both eyes as his intraocular pressure had been borderline high for his left eye and he was monocular. On December 8, 2018, the Veteran was seen for constant tearing on the outer corner of his right eye, with skin irritation from wiping it. He had mild epiphora on the lateral canthus with moderate amount of tear welling up in the crease of the lateral canthus and dispersed by the wrinkles; a little bit of it flowing laterally down the cheek. The impression was of right lower lid laxity with no punctal ectropiaconstant tearing with visible wetness on the lateral corner of the right eye resulting in visibly rough and red skin. He had been on a trial of taping but was not sure it had helped. A January 3, 2019 VA ophthalmology record included the Veteran's complaint of persistent epiphora of the right eye with edema and irritation. He reported a foreign body sensation in the right eye. On physical evaluation, mild epiphora was observed in the medial and lateral canthus with moderate amount of tear welling up in the crease of the lateral canthus. He had increased right lower lid laxity with minimal snapback when asked to look up. He had kissing puncta of the right upper and lower lids. Inferior punctum appeared patent, no punctal plugs. He had mild brow ptosis with bilateral dermatochalasis. As shown above, the Veteran's left corrected distance visual acuity fluctuated during the period from March 16, 2015 to March 26, 2019. The Board calculated the various combined ratings available based on the Veteran's visual field impairment and visual acuity during this period on appeal. The greatest combined rating shown was 80 percent when considering the Veteran's September 2015 visual acuity prior to laser treatment and his 2015/2017 visual field findings. The Board will apply the 80 percent rating for the entire period. A rating in excess of 80 percent is not shown for this period, as the remaining records showed visual acuity better than 20/60 except for the September 2015 record. Additionally, there is no indication of incapacitating episodes under the former regulation definition prior to March 2018, or under the revised definition from March 2018. From March 26, 2019 On March 26, 2019, the Veteran participated in a third VA fee-basis eye examination. He was diagnosed with corneal (graft) transplant with other complications, primary optic atrophy (right eye), end-stage primary open-angle glaucoma (right eye), and left eye visual field constriction from unknown etiology. He complained of blurry vision. He was on glaucoma medication to "keep the pressure down in the right eye." His corrected distance vision was 5/200 or worse (right) and 20/100 (left). His corrected near vision was 5/200 or worse (right) and 20/100 (left). He did not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between his corrected distance and near vision. He had light perception only in the right eye. He had a corneal irregularity that resulted in severe irregular astigmatism, but did not wear a contact. He did not have diplopia. Slit lamp evaluation showed right cornea graft, intact, hazy, neovascular. His right iris had an LPI (laser peripheral iridotomy) at 11 o'clock. He had bilateral PCIOL (posterior chamber intraocular lenses). On internal eye evaluation he had complete pallor and glaucomatous cupping of the right optic disc. Under "cornea" conditions, the Veteran was noted to have had a right corneal transplant which resulted in visual impairment as it was "hazy." He did not report any current residuals associated with the transplant (e.g. pain, photophobia, glare sensitivity). Under "glaucoma," the examiner selected that the Veteran had right open-angle glaucoma with use of continuous medication. Under "lens conditions," the Veteran had bilateral pseudophakia which did not result in his visual impairment. Under "neuro-ophthalmic conditions," the Veteran had right optic neuropathy which was the cause his decrease in visual acuity or other visual impairment. The examiner selected that the Veteran had not had any incapacitating episodes of an eye condition in the past 12 months (under the revised regulation definition). Under the section related to functional impact, the examiner noted that the Veteran had "no light perception in the right eye affecting his ability to drive due to the severe primary open angle glaucoma." The thinning and irregular astigmatism of the right eye was due to his corneal transplant. His visual field constriction was due to his glaucoma in the right eye. There was "no etiology...found for the cause of the field constriction in the left eye." Visual field testing showed complete loss of visual field of the right eye. He had visual field of 117 degrees for the left eye; divided by the 8 principal meridians, he had concentric contraction with remaining visual field of 14.625 degrees. The examiner noted "total loss of field in his right eye and constricted field in his left eye." He had a scotoma affecting at least 14 of the visual field of the right eye, and legal (statutory) blindness based on visual field loss. Under DC 6080, the Veteran's right remaining visual field should be evaluated as visual acuity of 5/200 (worst available), and his left concentric contraction with remaining visual field between 6 and 15 degrees should be evaluated as visual acuity of 20/200. Under DC 6065, visual acuity of 5/200 and 20/200 warrants a 70 percent rating. Under DC 6064, the Veteran's corrected visual acuity of 5/200 (right) and 20/100 (left) warranted a 60 percent rating. Combining the 70 percent (visual fields) and 60 percent (central visual acuity) ratings under 38 C.F.R. § 4.25 (combined rating table) shows the Veteran's visual impairment warrants a 90 percent rating based on the March 26, 2019 VA examination. On June 4, 2019, the Veteran reported to VA ophthalmology that both of his eyes had been "watery." He reported his left vision had been fluctuating over the past year, which he believed was due to the tearing. Regarding his left eye, he had PCIOL in 2008, and YAG peripheral iridotomy for narrow angles. He did not have left open angle glaucoma but "was a steroid responder." He had dry eyes and used artificial tears. His left corrected distance visual acuity was 20/50+1 left eye. Humphrey visual field testing had been stopped, with his last on August 20, 2012. Notably, the Veteran's left corrected central distance visual acuity was improved in the June 4, 2019 VA treatment record compared to the March 2019 VA examination. On July 12, 2019, the Veteran's wife submitted a statement in support of his TDIU claim wherein she reported his right eye would never improve and was "always discharge[ing] and watering." She also noted he had a balance "problem" and fell "often." On October 7, 2019, the Veteran again participated in a VA fee-basis eye examination. During service in Korea, he had a right corneal transplant with high intraocular pressure that ended his vision in his right eye. Since 2008, his left vision started to dim with constriction of the peripheral visual field. He reported a history of a stroke in August 2019 with a history of clot removal and worsening vision in his left eye. His corrected distance vision was 5/200 or worse right eye and 20/70 left eye. His corrected near vision was 20/70 left eye. During this examination, he did not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision. His right vision was limited to no more than light perception. He did not have diplopia. On slit lamp evaluation, he had right cornea scar and PKP (penetrating keratoplasty). He had bilateral centered PCIOL. On fundus (internal) evaluation, he had a pale nerve in the right optic disc. Visual field testing was completed, and the values were reported by the VA examiner. The Veteran had no remaining visual field for the right eye. He had a combined visual field of 20 degrees, divided by the 8 principal meridians, for a remaining field of 2.5 degrees. The examiner also selected that the Veteran loss of the temporal half, nasal half, inferior half, and superior half of his visual fields for both eyes. He also had a scotoma affecting at least 14 of his visual field in both eyes. He had legal (statutory) blindness based on visual field loss. The examiner selected that the Veteran had neuro-ophthalmic condition of optic neuropathy of both eyes, "non-ischemic optic neuropathy" resulting in his visual impairment. He had not had any incapacitating episodes (the revised definition) in the prior 12 months. Regarding the impact of his eye disability on his ability to work, the examiner wrote "has difficulty driving to work due to poor vision and poor visual field." In an attached medical opinion, the examiner noted that a March 1, 2018 VA treatment record showed the Veteran's reported of worsened eye symptoms since his examination in 2017, citing decreased vision and flare-ups since a January 2018 concussion. Following a review of the record, the examiner noted that the Veteran had severe flare-ups, "constant, every day," and that his poor vision in one eye resulted in difficulty driving. The Board notes that the October 2019 examiner recorded a medical history that the Veteran suffered a stroke in August 2019 resulting in decreased left vision. His left visual acuity had improved to 20/70 during the October 2019 (from 20/100 in March 2019); however, his remaining visual field for his left eye had further decreased. Thus, likely his decreased visual field for his left eye began with his August 2019 stroke. However, the treatment records related to this August 2019 stroke are not available. As such, the Board will provide the 100 percent rating from August 1, 2019 to provide the Veteran the greatest benefit given that the exact date of the stroke in August 2019 is unknown. In April 2021, the Veteran's representative provided a brief in support of the Veteran's claim, but did not address the 2019 stroke or additional left visual field loss. A rating in excess of 90 percent from March 26, 2019 to August 1, 2019 is not warranted. The Veteran's visual acuity during his March 26, 2019 examination was worse (20/100) than it was in June 2019 VA treatment records 20/50+ and the October 2019 examination (20/70). The Veteran reported worsening left vision following a stroke in August 2019, which was demonstrated in the left visual field testing between the March and October 2019 examinations. The Board is applying the October 2019 visual field findings to the earliest date in August (August 1, 2019) given that the day of the August 2019 stroke is unknown. Additional higher rating is not warranted based on incapacitating episodes, as none were shown in the record and the Veteran and his representative have not indicated he is receiving additional eye treatment outside of VA treatment. Lastly, the Board finds that a separate 20 percent rating is warranted for bilateral lacrimal apparatus disorder for the entire period on appeal (from March 16, 2015) Under 38 C.F.R. § 4.79, DC 6025, for disorders of the lacrimal apparatus (epiphora, dacryocystitis, etc.), a 20 percent rating is warranted for bilateral involvement. This DC remained unchanged by the 2018 amendments. The May 2015 VA examiner noted that the Veteran's bilateral blepharitis was a disorder of the lacrimal apparatus, and also diagnosed MGD. The Veteran was on dry eye medication (artificial tears) according to VA treatment records. Although a medical opinion was not provided regarding the cause of the Veteran's blepharitis/MGD/dry eyes, the Veteran had undergone surgery on both eyes and steroid treatment was provided for his service-connected right eye with treatment notes indicating his left eye was a "steroid responder." A January 2019 VA treatment record included the Veteran's complaint of epiphora, edema, tearing, and dermatochalasis. The Board will resolve reasonable doubt in the Veteran's favor that his blepharitis/MGD/dry eyes/right eye tearing are due to his service-connected bilateral eye disorders, and will provide a separate 20 percent rating. As DC 6025 does not provide a rating based on visual impairment, the separate 20 percent rating does not result in pyramiding. REASONS FOR REMAND 1. Entitlement to an increased SMC rating is remanded. The Board considered whether additional benefits were available to the Veteran for the period covered by this appeal, from March 16, 2015 onward. The Veteran is in receipt of TDIU for his eye disabilities alone for the entire period on appeal. He is in receipt of SMC (k) for light perception only in his right eye, for the entire period on appeal. He is also in receipt of SMC (s) for one disability warranting a 100 percent rating, and a second disability warranting a rating of 60 percent or greater from January 17, 2019. An earlier effective date for the grant of SMC (s) is not warranted as the Veteran's hepatitis C was increased to a 100 percent rating on January 17, 2019, and his combined ratings for his hepatitis C, right elbow strain, tinnitus, and hearing loss did not meet the statutory requirements for entitlement to SMC (s) prior to January 17, 2019. SMC (m) is provided where visual field is reduced to 5 degrees concentric contraction in both eyes, "entitlement on account of need for regular aid and attendance will be determined on the facts in the individual case." During the October 7, 2019 VA examination, the Veteran was shown to have concentric contraction of his left visual field to less than 5 degrees and he has had no right visual field for the entire period on appeal. It is unclear from the available evidence whether the Veteran is in need of regular aid an attendance. On remand, the Veteran must be afforded a VA aid and attendance examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA aid and attendance examination to determine the impact of his visual impairment in conjunction for consideration for an increased SMC rating, to include SMC (m). 2. After completing the development requested above, readjudicate the Veteran's claim. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. Stubbs, 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.