Citation Nr: 21029914 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 19-13 071 DATE: May 17, 2021 REMANDED Entitlement to service connection for residuals of head injury, claimed as traumatic brain injury (TBI), to include loss of vision, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from June 1958 to May 1961. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2017 rating decision. In July 2020, the Board remanded these matters for further evidentiary development. The scope of a disability claim includes any disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record. See Brokowsky v. Shinseki,23 Vet. App. 79, 84 (2009). Mindful of this, the Board has more broadly characterized the claim of TBI as a claim for residuals of head injury based on the Veteran's description of the event. Entitlement to service connection for residuals of head injury, claimed as TBI, to include loss of vision, is remanded. Pursuant to the July 2020 Board remand, the Veteran underwent VA examination in November 2020. The Board requested an addendum medical opinion from an appropriate clinician on whether the Veteran has residuals of head injury, claimed as vision loss (other than refractive error). The VA opinion was to include a discussion of the Veteran's documented history and assertions. The examiner was asked to specifically opine whether any current eye disability is at least as likely as not related to the head injury in service. The examiner was also asked to identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). On November 2020 VA examination, primary open-angle glaucoma, left eye, severe stage was diagnosed. The examiner opined the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained, After reviewing the claims file and the patient's history, it seems that ocular hypertension is the cause of his glaucomatous optic nerve damage. High eye pressure was first noted in 2016. I see no evidence of the in-service head injury related to eye condition noted on [examination]. The Board finds the medical opinion does not support the conclusion reached with reasoned medical explanation. Nieves-Rodriguez v. Peake,22 Vet. App. 295, 301 (2008). Specifically, the opinion made no attempt to explain why it is likely that hypertension is the cause of the Veteran's glaucomatous optic nerve damage and less likely that the Veteran's head injury in 1958 resulted in or caused the development of the left eye disorder diagnosed more than 50 years after injury the in service. Furthermore, the examiner employed speculative language ("it seems that ocular hypertension is the cause of his glaucomatous optic nerve damage") and the Board cannot rely upon this opinion, as medical opinions expressed in such speculative language ("seems to be") are inadequate. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Therefore, a remand for an adequate medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a Board remand confers a right on a claimant to compliance with the remand order). The matters are REMANDED for the following action: 1. Arrange for the Veteran's claims file to be forwarded to an appropriate clinician for review and an addendum medical opinion addressing whether he has residuals of head injury, claimed as vision loss (other than refractive error). The opinion should respond to the following: Is it at least as likely as not (a 50% or better probability) that any current eye disability (was first manifested in, or is otherwise etiologically related to) the Veteran's active service, to include as due to a head injury in service? The medical opinion must, among other things, include a discussion of the Veteran's documented history and assertions; it must also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 2. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion sought cannot be provided without resort to mere speculation, ensure that the clinician has so indicated, explaining why resort to mere speculation is required. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Griffith 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.