Citation Nr: 21030826 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 11-27 271 DATE: May 19, 2021 REMANDED Entitlement to service connection for a bilateral eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1970 to November 1972. This matter comes before the Board of Veterans' Appeals (Board) from an April 2012 rating decision. The matter was denied by the Board in March 2018. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (CAVC) and a Joint Motion for Remand was entered in January 2019. This matter was most recently remanded by the Board in August 2019 and September 2020. 1. Entitlement to service connection for a bilateral eye disorder is remanded. The Board regrets further delay however, another remand is necessary. In its September 2020 remand, the Board ordered that a VA opinion be obtained as to whether it is at least as likely as not that 1) the Veteran's current right or left eye disabilities were incurred in or causally related to his service and 2) whether his eye disabilities were caused or aggravated by any of his service-connected disabilities, to include diabetes, hypertension, coronary artery disease, and unspecified trauma and stressor related disorder. In February 2021, the Veteran underwent a new VA examination. The examiner did not complete the section of the form asking for an opinion as to whether any of the Veteran's service-connected disabilities caused his right or left eye disability. The examiner did check the section indicating that the Veteran's right and left eye disabilities were not aggravated by his service-connected disabilities. However, the provided rationale discussed only that the Veteran's cataracts were not caused by his service-connected diabetes or medication prescribed for his psychological condition or hypertension. Similarly, the provided rationale for macular degeneration explained that medical literature does not support that macular degeneration is caused by the Veteran's service-connected conditions or medication. Finally, the examiner stated that dermatochalasis is an age-related condition with no further discussion. The Board finds that an addendum medical opinion should be obtained that clearly specifies both whether it is at least as likely as not that the Veteran's eye disability was caused by service as well as whether it is at least as likely as not that the Veteran's eye disability was aggravated by any of his service-connected disabilities. A full rationale must be provided for both opinions. The Board notes that in service, the Veteran sustained an injury to his left eye, including lacerations to the area around the eye. The February 2021 examiner did not provide an opinion with rationale as to whether the diagnosed dermatochalasis is etiologically related to the in-service injury. Such an opinion is necessary. The Board further notes that medical records from 2018 indicate the Veteran was experiencing blurred and double vision which was corrected when he began taking daily aspirin for his heart. This apparent connection between the Veteran's medication for his heart and his vision should be addressed by a VA examiner. An addendum VA examination is needed to address the etiology of all disabilities impacting the Veteran's right and left eyes and to address the impact of the Veteran's other service-connected disabilities, including treating medication, on his eye conditions. The matters are REMANDED for the following action: Obtain a VA opinion that addresses the nature and etiology of the Veteran's right and left eye impairments, including cataracts, macular degeneration, and dermatochalasis. If deemed necessary by the examiner, schedule the Veteran for an examination. The examiner should provide an opinion, with full rationale, as to each of the following: (a.) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's current right or left eye disability, to include cataracts, macular degeneration, and dermatochalasis, was incurred in, aggravated by, or is otherwise etiologically related to the Veteran's active duty service. In providing this opinion, the examiner must consider the Veteran's February 1972 in-service injury and treatment for a hyphema and glaucoma. See December 2019 STR, pp. 1-11, 16-26. The Veteran's in-service left eye injury, including lacerations to the area around the eye, should be discussed specifically. (b.) Whether it is at least as likely as not that the Veteran's right or left eye disability is caused or aggravated by to a service-connected condition, including diabetes, hypertension, coronary artery disease, and unspecified trauma and stressor related disorder. In providing this opinion, the examiner must consider any medications used to manage these disabilities as well as the medical literature referenced in the Veteran's February 2018 appellate brief. See February 2018 Appellate Brief, pp. 1-2. The Veteran's treatment with aspirin should be discussed specifically. The examiner must ensure that both causation and aggravation are addressed and a full rational provided for each. Amanda Christensen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rekowski 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.