Citation Nr: 21029961 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 10-49 598 DATE: May 17, 2021 ORDER Service connection for a bilateral eye disorder, to include glaucoma and cataracts, and to include as secondary to service-connected diabetes mellitus and herbicide exposure is denied. FINDING OF FACT The competent and probative evidence of record demonstrates that the Veteran's currently diagnosed eye disorder, to include glaucoma and cataracts are not related to his military service, to include as due to in-service exposure to herbicide agents, or secondary to his service-connected diabetes mellitus. CONCLUSION OF LAW The criteria for service connection for an eye disorder, to include glaucoma and cataracts are not met. 38 U.S.C. §§ 105, 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1968 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was last before the Board in February 2021, when it was remanded for further development. The Veteran claims entitlement to service connection for an eye disorder, to include glaucoma and cataracts. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain chronic diseases, including hypertension, become manifest to a degree of 10 percent or more within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. A Veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era also will be presumed to have been incurred in service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). This presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). There is no question the Veteran had service in-country in Vietnam, and he is therefore presumed to have been exposed to herbicide agents. However, eye disabilities are not among the diseases that are associated with herbicide exposure for purposes of this presumption. 38 C.F.R. § 3.309(e). The Secretary, under the authority of the Agent Orange Act of 1991 and based on the studies by the National Academy of Sciences (NAS), has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. That being said, even if a Veteran is found not entitled to a regulatory presumption of service connection, the claim still must be reviewed to determine whether service connection may be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed Cir. 1994). See also, McCartt v. West, 12 Vet. App. 164, 167 (1999) (the principles set forth in Combee, which instead concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). Review of the Veteran's service treatment records (STR) indicates that in February 1969, the Veteran reported that sunlight was hurting his eyes. He was referred to optometry as told to wear sunglasses. In September 1969, the Veteran received treatment for his right upper eyelid. In April 1970, he was treated for a right eye sty for three day, causing him pain. On his separation report of medical history in January 1971, the Veteran reported having eye trouble in service. The board notes that the Veteran's military occupational specialty (MOS) as a photo lab specialist. In January 1987, the Veteran submitted a claim stating that his glaucoma developed from photophobia. An April 1987 VA examiner noted that the Veteran has had photophobia since 1969 and a history of glaucoma several years ago. A June 2003 treatment note showed that the Veteran was being treated for open angle glaucoma. In a May 2008 statement, the Veteran reported that he wore dark glasses for eye protection. A June 2009 VA examiner diagnosed refractive error and a November 2009 VA treatment record reflect a diagnosis of cataracts. The Veteran was afforded a VA examination in June 2009. Based on a review of the records, the examiner noted that the Veteran had a history of chronic open angle glaucoma which had been controlled with medication since 2002. The examiner indicated that there were no records indicating the condition was diagnosed or treated during the Veteran's military service. He had an acute diabetic crisis in June 2008 which required hospitalization. The diabetes had recently been under good control without any secondary ocular or visual problems. The examiner opined that it was more likely than not that the eye condition of glaucoma was not secondary to diabetes and appeared to have developed after military service. In August 2016, a VA examiner diagnosed bilateral primary open angle glaucoma, bilateral diabetes without diabetic retinopathy and bilateral pseudophakia. The examiner stated that the Veteran demonstrated constriction of his visual fields in both eyes that was consistent with his diagnosis of glaucoma. The Veteran had open-angle glaucoma which had known associations with family history, trauma, and steroid use. The examiner indicated that the Veteran had no evidence of traumatic glaucoma on his examination and furthermore denied a history of trauma sustained in his past. On review of all available medical records on VBMS, there was no documentation of exam findings consistent with a diagnosis of glaucoma during that time in the service. However, the examiner noted that there was no complete eye examination where there was documentation of what his eye pressure or optic nerves looked like. The examiner further indicated that there are were no eye examination notes to review from 1971 to 2003. The examiner opined that it was at least as likely as not that his glaucoma was incurred in or caused by service. The examiner provided the rationale that glaucoma, without a history of eye trauma, typically occurs in older adults. The Veteran left service while he was in his early twenties. The August 2016 examiner also opined that it is less likely than not that the Veteran's glaucoma was caused or aggravated beyond its natural progression by his service connected diabetes mellitus type II. The examiner provides the rationale that there is no connection between glaucoma and diabetes. This is because diabetes had no known direct risk with the development of open-angle glaucoma or known secondary or aggravation risks associated with glaucoma. Thus, the glaucoma with visual field constriction was less likely than not proximately due to or the result of the Veteran's diabetes. In November 2016, the same examiner from August 2016 entered an opinion that that glaucoma was "LESS LIKELY than not" incurred in or caused by service. Due these inconsistent opinions, the matter was remanded October 2017. In November 2020, a VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the rationale that open angle glaucoma was likely a hereditary disease that occurs with aging. He explained that the Veteran did not have a history of neovascular glaucoma, the type that is connected to diabetic retinopathy. The examiner also noted that that there was no evidence directly relating herbicide to cataracts. Cataracts were normally associated with aging. In addressing aggravation, the November 2020 examiner noted that the Veteran had no visual field loss due to glaucoma treatment over the years. He had mild glaucoma with no visual field loss. His open angle glaucoma had been and was well-controlled. The condition was noted to have started with light sensitivity-photophobia. Cataracts were corrected by surgery in 2009. Prior to cataract surgery he had to wear much stronger prescribed spectacle. Cataract surgery improved vision greatly. In March 2021, a VA examiner opined that it was less likely than not that any currently diagnosed eye disorders, including glaucoma and cataracts, were caused by service and/or proximately due to and/or aggravated by the Veteran's service to include his service-connected diabetes mellitus. The examiner provides the rationale that as per medical record review, the Veteran's glaucoma was diagnosed in 1987 and was treated with Cosopt eye drops. The Veteran's cataracts were diagnosed in 2009 and was successfully treated with cataract surgery. The examiner opined that the open angle glaucoma was less likely than not aggravated by the Veteran's diabetes. He explained that diabetes caused neovascular type glaucoma which this Veteran did not have. The most common risk factors for open angle glaucoma were age, family history and race. The examiner also opined that the cataracts were less likely than not due to diabetes and were due to normal aging progression and not diabetes or herbicide exposure. He explained that the most common cause of nuclear cataracts was age related. Diabetes caused cortical cataracts, which the Veteran was not found to have in service. The glaucoma was not congenital and was not due to herbicide exposure. The cataracts were less likely than not due to diabetes and were at least as likely as not due to normal aging progression and not diabetes or herbicide exposure. Based on a review of the record, he opined that it was less likely than not that any currently diagnosed eye disorder, including glaucoma and cataracts, had its onset during or is otherwise etiologically related to the Veteran's military service, to include exposure to herbicide agent. In March 2021 addendum, the examiner noted the Veteran's 1987 complains that his glaucoma was due to photophobia. The examiner opined that this was less likely than not true as there was no medical evidence in the literature to support that glaucoma was caused by photophobia. As the cataracts were not noted until 2008 many years after the 1971 complaint of eye trouble, they most likely formed with natural aging progression and were not due to eye complaints in 1971. The refractive error was a developmental eye condition and is not due to the 1971 reports of eye trouble. With respect to the Veteran's January 1971 separation report of medical history indicating eye trouble and the Veteran's January 1987 claim that his glaucoma developed from photophobia, the March 2021 examiner opined that it is less likely than not true as there is no medical evidence in the literature to support that glaucoma is caused by photophobia. The Veteran's glaucoma was open angle and was also less likely than not due to his diabetes which caused neovascular type glaucoma which the claimant does not have. He explained that as individuals age with open-angle glaucoma, the trabecular meshwork did not function as well, which affected how fluid flowed out of the eye, and gradually eye pressure developed over time. This condition would have developed in the absence of military service and was neither caused by nor exacerbated by it. The examiner further noted that current medical literature as well as his expertise in this area did not support that a nexus can be established between the current eye disabilities, including glaucoma and cataracts, and military service. With respect to the Veteran's May 2008 statement that he wore dark glasses for eye protection, the March 2021 examiner noted that this was after the active duty dates and, as previously mentioned, there was no medical literature to support a causative relationship between photophobia and either glaucoma or cataracts. With respect to the July 2009 VA examination diagnosing a refractive error; and November 2009 treatment records reflecting a diagnosis of cataracts, the March 2021 examiner indicated that the Veteran's cataracts were not noted until many years after the 1971 complaint of eye trouble. He explained that they most likely formed with natural aging progression and were not due to eye complaints in 1971. The refractive error was a developmental eye condition and was not due to the 1971 reports of eye trouble. After reviewing the STRs the examiner reiterated his opinion that the Veteran's current eye conditions, to include glaucoma and cataracts, were not incurred in nor aggravated by service. There is also no medical literature to support they were caused by another service-connected condition. The Veteran's conditions would have occurred as part of the normal aging progression. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection. The March 2021 VA opinions are the most probative evidence of record. The VA ophthalmologist is qualified through education, training, and experience to offer medical diagnoses, statements, or opinions. Moreover, the opinions reflect consideration of the Veteran's history, to include his treatment for his eye disability, and his statements concerning the onset of his visual problems. The examiner offered the opinions based on a review of the Veteran's VA e-folder and medical literature. The VA examiner supported the opinions with thorough rationale and noted other factors that were more likely to have caused or aggravated the Veteran's eye disabilities, including age and hereditary factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) ("[A] medical opinion... must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions."). The Board acknowledges the Veteran's contentions that his eye disability is related to his military service, to include as due to his in-service exposure to herbicide agents, or secondary to his service-connected diabetes. While he is competent to report his in-service symptoms, he is not competent to opine on complex medical questions such as the etiology of his current eye diagnoses. Specifically, where the determinative issue is one of medical causation as presented here, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). The question of causation or aggravation of an eye disability involves a medical subject of an internal physical process extending beyond the immediate observable cause-and-effect relationship. As such, the determination of the etiology of his eye disability requires a specialized understanding of the medical nature and pathology of the disorder(s), which he has not been shown to have. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's lay statements are not considered competent on that issue. Moreover, the Board finds that the Veteran may not prevail under the presumptive provisions governing service connection for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Although such diseases include disabilities of the central nervous system, service connection would not be warranted unless the eye disability manifested to a compensable degree within a year of the Veteran's release from active service in May 1971, or if he exhibited a continuity of symptomatology since that time. In this case, there is no competent evidence of record which demonstrates that an eye disability manifested to a compensable degree within one year from discharge, and there is no evidence demonstrating a continuity of symptoms following service. In fact, the record shows that the Veteran was not diagnosed with any eye disability until many years after service. Continued on Next Page In conclusion, the Board finds that the claim for service connection for bilateral eye disorder, to include glaucoma and cataracts, and to include as secondary to service-connected diabetes mellitus and herbicide exposure must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as no competent and probative evidence supports the required elements of his claims, that doctrine is not applicable. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Asare, 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.