Citation Nr: 21031622 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 08-04 494 DATE: May 24, 2021 ORDER Entitlement to service connection for an eye disability, to include as secondary to a service-connected disease or injury is denied. FINDINGS OF FACT 1. The Veteran's eye disorder is unrelated (causation or aggravation) to a service-connected disease or injury. 2. A chronic eye disease (glaucoma) was not manifest in service or within one year of separation and is not otherwise attributable to service. 3. Refractive error has been identified. 4. Cataracts, pinguecula and blepharitis were not manifest in service and are unrelated to service. 5. The Veteran does not have diabetic retinopathy. CONCLUSIONS OF LAW 1. An eye disorder is not proximately due to or a result of or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. 2. An eye disability was not incurred in or aggravated by service and glaucoma and retinopathy (organic disease of the nervous system) may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. Refractive error is a not a disease or injury within the meaning of the law providing compensation. 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1970 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Board remanded this case for further development. The September 2020 remand required that the VA schedule the Veteran for an examination to obtain an additional addendum opinion. Accordingly, the Board's remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for an eye disability, to include as secondary to service-connected diabetes mellitus type II The Veteran contends that he has an eye disability that is due to his service. He alternatively contends that his eye disability is secondary to his service-connected diabetes mellitus, type II. Pertinent Legal Criteria Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection for an organic disease of the nervous system may be presumed if manifest to a compensable degree within one year o separation. The Board notes that the Veteran has not claimed that his disabilities on appeal are the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C. § 1154 are not for consideration. Service connection is warranted for disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). Direct Service Connection The Board notes that Veteran's service treatment records are silent of any complaints or injuries related to the Veteran's eyes. The Board notes that on Veteran's September 1971 discharge examination, Veteran denied a history of eye trouble. The discharge examination disclosed the eyes were normal on clinical evaluation and acuity was 20/20 in each eye. In March 1975 the Veteran was provided an examination. Veteran denied a history of eye trouble. Veteran did not specifically receive an eye examination during this examination. In February 1983 Veteran was provided an examination. The Veteran reported that he had vision in both eyes and that he did not wear glasses or contact lenses. The Veteran denied a history of eye trouble. An eye examination was provided and reported the Veteran had vision acuity of 20/20 in each eye. The clinical evaluation of the eyes was normal. A periodic examination was provided to the Veteran in November 1987. Veteran's eyes were evaluated as normal. Acuity was 20/20 in each eye. The Veteran was provided an examination in March 1994. The Veteran reported that he was wearing glasses and had vision in both eyes. The Veteran denied a history of eye trouble. Veteran's eyes were examined which were noted as normal. Vision acuity was corrected to 20/20 in each eye with use of lenses. Acuity was otherwise 20/50 in each eye. Veteran filed an application for compensation or pension in March 2006. The Veteran claimed diabetic retinopathy and claimed that his disability began in June 2000. On the application Veteran claimed he began treatment in June 2003 and was still receiving treatment. The Veteran was provided a compensation and pension examination on May 2006. He voiced complaints of burning ocular sensations and occasional itching, but denied ocular pain. The Veteran was diagnosed with refractive error, blepharitis, and incipient senile cataracts with good corrected visual acuity. The examination noted no diabetic retinopathy. The examiner concluded that the Veteran's loss of vision was caused by or a result of his refractive error and symptoms of the blepharitis. The examiner also stated that the loss of vision, including cataracts, was not caused by or a result of diabetes mellitus, type II. A VA examination was provided to the Veteran May 2017. The examiner reviewed the Veteran's record including the May 2006 examination and provided a physical examination. The examiner stated that there was no evidence of diabetic retinopathy or blepharitis at the examination. Further the examiner noted that there was no evidence of macular edema and that Veteran's eye lids were normal. During the May 2017 examination, corrected distance and corrected near eyesight for both eyes was 20/40 or better. There was no anatomical loss, light perception only, extremely poor vision or blindness of either eye noted. The examiner noted that Veteran did not have a corneal irregularity that resulted in severe irregular astigmatism or diplopia. The lids, lashes and external eyes were normal. Veteran's left conjunctiva had a tiny pinguecula, while normal for the right. Both of Veteran's cornea were described as arcus senile. The Veteran's anterior chambers and irises were normal. Both of Veteran's lenses were noted with nuclear sclerosis, cortical peripheral changes. There were right and left eye vitreous floaters. The examiner opined that Veteran's refractive error was not caused or was the result of active service nor was aggravated as the result of active service. The examiner's rationale was that the refractive error was considered to be congenital and developmental in origin. The examiner opined that the Veteran's senile cataract changes were not the result nor were aggravated by active service. The examiner explained that senile cataract changes are to be expected in a 66-year-old person such as the Veteran at the time of the examination. The examiner stated that studies demonstrate that 95% of persons 65 years and older can present some degree of crystalline lins opacification producing light scattering and blurring of the vision. The examiner noted a tiny pinguecula in the left eye found during the examination. The examiner stated that pinguecula are superficial conjunctival actinic changes affecting the collagen and elastoid fibers of the conjunctiva. The examiner opined that the pinguecula in the left eye was not caused or the result of active service, nor was aggravated by active service. The examiner diagnosed Veteran with the previously mentioned small pinguecula in the left eye and nuclear sclerosis bilateral. The examiner stated that the pinguecula did not cause any decrease in visual acuity or other visual impairment. Further it was noted that the pinguecula did not cause any scarring or disfigurement. The nuclear sclerosis was associated with the senile cataract changes Veteran had claimed. The examiner noted that there was no scarring or disfigurement attributable to any eye condition and that the Veteran did not have any incapacitating episodes attributable to any eye condition in the past 12 months. The examiner stated as well that the eye conditions did not impact Veteran's ability to work. The examiner noted that while Veteran presented a reduction in visual acuity due to refractive error, it could be corrected with glasses. In a November 2018 Board remand, the Board combined the issues of refractive error, blepharitis, and senile cataracts into service connection for an eye disability. The Board noted as well that the May 2017 examination failed to address the etiology of the blepharitis that was noted on the May 2006 examination. The Board remand instructions provided that an additional addendum opinion addressing the blepharitis. An additional addendum opinion was provided on June 2020 by the previous VA examiner. The examiner opined the Veteran's blepharitis is less likely than not incurred or had an onset during Veteran's active duty and is less likely than not caused or otherwise related to Veteran's military service. The examiner stated that Veteran was diagnosed with blepharitis in 2006 and that Veteran's last evaluation in 2019 showed no evidence of blepharitis. The Board noted that the examination failed to provide a direct opinion to blepharitis that encompassed the entire period on appeal. The Board's remand instructions included a proper opinion and if blepharitis was found to be not directly related to military service, then the examiner must opine if it was secondary connected to Veteran's service-connected diabetes mellitus, type II. In accordance with the Board's previous remand, an additional VA examination was provided to the Veteran in October 2020. The VA examiner opined that it was less likely than not that Veteran's blepharitis had its onset during active service or was related to his active service. The examiner stated that the service treatment records were silent on this condition and that this condition is very common in aging persons. The examiner further stated that after review of the record, there has been no subsequent evidence of blepharitis after his initial examination in 2006. The condition had not been noted in any of the subsequent evaluations or examinations since it was identified in the 2006 examination. The Board notes that Veteran claimed that his condition started in June 2000 and he started receiving treatment for his eyes in June 2003. The Veteran's enlistment and discharge examinations disclose that the eyes were normal, and he denied a pertinent history of eye trouble. Furthermore, evaluation of the eyes was normal in 1975, 1983, and 1987. The Veteran does state that he started receiving treatment in June 2003, but even if he did the active service ended almost 30 years earlier in 1971. In this case, the record establishes the post service development of refractive error, blepharitis, glaucoma, cataracts and pinguecula. However, no eye pathology was identified during service or in proximity thereto. The May 2017 examination provided a negative nexus opinion for the Veteran's senile cataract changes and refractive error. The examiner provided a detailed examination of Veteran's eyes including the severity of Veteran's vision impairment. Further the May 2017 examiner found additional eye conditions that were resolved as not being attributable to service. The detail and extent that the May 2017 examiner covers provides a large amount of probative value against Veteran's claims. The Board does note that even though the May 2017 examination did not address Veteran's blepharitis its probative weight is still significant. The May 2017 examiner provided the Veteran a sufficient eye examination and properly opined the negative nexus responses. While the May 2017 examiner did not address Veteran's blepharitis this was correctly addressed by the later October 2020 examination. The examiner noted that there was no evidence in Veteran's service treatment records of blepharitis. Further the examiner noted that Veteran was only noted to have blepharitis in his 2006 examination, but not on his 2007 evaluation, 2017 examination and 2019 evaluation. This examination provides great probative weight in that the examiner takes note of the previous examination findings. The Board finds the probative value of the May 2017 and October 2020 examinations read in conjunction with the Veteran's service records sufficient conclude that the Veteran's disability is not attributable to active service. Here the preponderance of the evidence is against the Veteran's claim for a direct service connection for any eye disability. In regard to glaucoma (an organic disease of the nervous system), such was not manifest, noted or diagnosed in service or within one year of separation. Rather, the service separation examination disclose that the eyes were normal and subsequent examinations in proximity to separation were normal. In regard to the assertion of retinopathy, such pathology has never been identified. It stands to follow that retinopathy was not noted, diagnosed or manifest in service or within one year of separation from service. Secondary Service Connection Within the October 2017 addendum opinion, the VA examiner provided an opinion on a secondary service connection. The VA examiner opined that Veteran's refractive error was less likely than not proximately the result of Veteran's service-connected diabetes mellitus, type II, nor less likely than not proximately caused or related to blepharitis, nor less likely than not proximately due or related to senile cataract changes. The examiner used the same rationale for the direct service connection opinion in that refractive errors are considered congenital and developmental in origin. The VA examiner opined that the Veteran's senile cataract changes were less likely than not proximately the result of diabetes mellitus II and are not proximately relate nor caused by a previous episode of blepharitis in May 8, 2006. The examiner stated that studies indicated that senile cataract changes are expected in person's that are Veteran's age and older. The examiner addressed the pinguecula found in Veteran's left eye during the May 2017 examination. The examiner opined that the tiny pinguecula was not the result of diabetes mellitus, nor senile cataracts, nor a previous episode of blepharitis on May 8, 2006. The examiner stated that pinguecula are only superficial conjunctival actinic changes. On October 2017, an opinion was provided in order to apply the specific standard the VA requested. The examiner also opined that the Veteran's refractive error was not caused or permanently aggravated by Veteran's service-connected diabetes mellitus. The examiner stated that Veteran's refractive error is congenital and developmental in origin. The examiner then opined that Veteran's senile cataract changes are not proximately caused or permanently aggravated by Veteran's service-connected diabetes mellitus. The examiner explained that senile cataract changes are expected in people 65 years and older. The examiner stated that there are studies demonstrating that 95% of persons 65 years and over can present with some degree of crystalline lens opacification, producing light scattering and blurring of the vision. The Veteran was at 66 years old at the time of this examination. The examiner opined the Veteran's pinguecula in the left eye was not proximately caused or permanently aggravated by Veteran's service-connected diabetes mellitus. The examiner's rationale was that pinguecula are superficial conjunctival actinic changes. In a November 2018 Board remand, the Board noted that the May 2017 examination and October 2017 addendum opinion failed to address the etiology of the blepharitis that was noted on the May 2006 examination. The Board remand instructions demanded for an additional addendum opinion addressing if blepharitis was proximately caused by or permanently aggravated by Veteran's service-connected diabetes mellitus, type II. An additional VA addendum opinion was provided June 2020. The VA examiner opined that it was less likely than not that Veteran's blepharitis was proximately caused by or permanently aggravated by his service-connected diabetes mellitus type II condition. The examiner stated that there was no evidence of blepharitis on Veteran's examination in May 2017 or his last evaluation in October 2019. The examiner explained that blepharitis is very common in an aging person and that the records present no evidence of blepharitis between 2017 to 2019. The subsequent VA medical opinion was provided on October 2020 and provided a negative direct service connection opinion. The VA examination provided a negative secondary service connection opinion as well. The VA examiner opined that it was less likely than not that the Veteran's claimed blepharitis was proximately caused by or permanently aggravated by his service-connected diabetes mellitus type II condition. The examiner explained that his rationale was that there was no evidence of blepharitis present after his 2006 evaluation. The VA examiner further opined that Veteran's refractive error was less likely than not proximately due to the result of his service-connected diabetes mellitus type II. The VA examiner opined as well that Veteran's refractive error was not caused or related to Veteran's previous episode of blepharitis nor is due or related to his senile cataract changes. The examiner used the same rationale that was used for the October 2017 opinion citing that that refractive errors are considered congenital and developmental in origin. The VA examiner noted that the examination in 2016 and 2017 Veteran presented evidence of senile nuclear sclerosis. The VA examiner opined that Veteran's senile cataract changes were less likely than not proximately due to the result of Veteran's service-connected diabetes mellitus type II. The examiner also opined that Veteran's senile cataract changes were not proximately related or caused by Veteran's episode of blepharitis. The VA examiner's rationale was that studies demonstrate that 95 percent of persons near 65 years or older will present some degree of crystalline lens opacification. The examiner explained that senile cataract changes are to be expected in a 66-year older person such as the Veteran. The Board notes that Veteran is service connected for diabetes mellitus, type II. However, there is no competent evidence of any relationship (causation or aggravation) to a service-connected disease or injury. The Veteran's own assertion is not competent and is not supported by competent evidence. To the extent that he asserts that there is diabetic retinopathy, the VA examinations establish that such disease process is not present. It follows that in the absence of such pathology, a service-connected disease did not cause or aggravate a disorder that does not exist. Refractive error, standing alone, is not a disease or injury for compensation purposes. To the extent that there are other pathologies, in addition to the refractive error, there is no association (causation or aggravation) to the service-connected disease or injury. Conclusion For the reasons and bases expressed above, the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for any eye disability, to include as secondary to service-connected disease or injury. The benefits sought on appeals are accordingly denied. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Konieczny, Adam 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.