Citation Nr: 21031754 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 15-42 799A DATE: May 24, 2021 ORDER Entitlement to service connection for a left ear hearing loss disability is granted. Entitlement to service connection for a right ear hearing loss disability is denied. Entitlement to service connection for a back disorder is denied. Entitlement to service connection for type 2 diabetes is denied. Entitlement to service connection for a heart disorder, to include chest pain, is denied. Entitlement to service connection for a stomach disorder, to include abdominal pain, is denied. Entitlement to service connection for a bilateral vision disorder, to include diabetic retinopathy and cataracts, is denied. REMANDED Entitlement to service connection for a headache disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's left ear hearing loss is related to in-service noise exposure. 2. The preponderance of the evidence is against finding that the Veteran's right ear hearing loss is related to in-service noise exposure; and there is no evidence of right ear hearing loss manifested to a compensable degree within one year following discharge from active service. 3. The preponderance of the evidence is against finding that the Veteran's back disorder began during or is otherwise related to active service or events therein; and there is no evidence of lumbar spine arthritis manifested to a compensable degree within one year following discharge from active service. 4. The preponderance of the evidence is against finding that the Veteran's type 2 diabetes began during or is otherwise related to active service or events therein, to include exposure to contaminated water; and there is no evidence of diabetes manifested to a compensable degree within one year following discharge from active service. 5. The preponderance of the evidence is against finding that any heart disorder, to include chest pain, began during or is otherwise related to active service or events therein, to include exposure to contaminated water; and there is no evidence of cardiovascular disease manifested to a compensable degree within one year following discharge from active service. 6. The preponderance of the evidence is against finding that the Veteran has a stomach disorder, to include abdominal pain, that began during or is otherwise related to active service or events therein, to include exposure to contaminated water. 7. The preponderance of the evidence is against finding that the Veteran has a bilateral vision disorder, to include diabetic retinopathy and cataracts, that began during or is otherwise related to active service or events therein, to include exposure to contaminated water. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for left ear hearing loss have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. 3. The criteria for service connection for a back disorder have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for service connection for type 2 diabetes have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for service connection for a heart disorder, to include chest pain, have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for service connection for a stomach disorder have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 7. The criteria for a bilateral vision disorder, to include diabetic retinopathy and cataracts, have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1976 to February 1979. Most recently, the Board remanded the listed issues in October 2020. The Veteran submitted additional evidence following the February 2021 supplemental statement of the case. Automatic waiver applies. 38 U.S.C. § 7105(e). The prior remand directed the agency of original jurisdiction (AOJ) to request service treatment and personnel records pertaining to the Veteran's Reserve service (1979 to 1985). The records were requested, and response received in December 2020 indicates that all available service treatment records were previously uploaded. The AOJ did not specifically notify the Veteran that it was unable to obtain additional records as directed. Notwithstanding, review of the claims folder shows that it does contain personnel records pertaining to the Veteran's period of Reserve service. Specifically, these records indicate he was assigned to the "Ready Reserve (IRR)" following his period of active service and his primary duty is listed as "inactive." He was assigned to the individual ready reserve and there is no indication that he participated in weekend drills, annual training, or was otherwise recalled to active duty nor has he contended as such. Also, except for his report that he was on diabetes medication while in the Reserves, he has not specifically claimed that any of the disorders are related to disease or injury during a period of active duty training or inactive duty training. Thus, the Board finds substantial compliance with the remand directives. Dyment v. Principi, 13 Vet. App. 141 (1999) (it is substantial compliance with remand orders that is required). Further efforts to obtain records relating to this period of service are not warranted. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. Active service is defined to include any period of active duty for training in which the individual was disabled or died from a disease or injury incurred or aggravated in the line of duty and any period of inactive duty for training during which the individual was disabled by an injury that was incurred or aggravated in the line of duty or from an acute myocardial infarction, cardiac arrest, or cerebrovascular accident occurring during such training. 38 U.S.C. § 101(24). The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Regarding the service connection claims decided herein, the Veteran contends that his disorders either began during or are otherwise related to active service or events therein, to include exposure to contaminated water at Camp Lejeune. As a lay person, however, he has not shown he has the medical training, experience, or expertise to be competent to diagnose the claimed disorders or to provide a medical etiology opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran's unsupported lay statements are insufficient to establish in-service onset or nexus. The Veteran was not provided VA examinations to address the etiology of his claimed back disorder, diabetes, heart disorder, or stomach disorder. Other than the Veteran's lay assertions, the record does not contain information suggesting a relationship between the claimed disorders and active service or events therein. The Veteran's own conclusory generalized lay statement that a service event or illness caused his current condition is insufficient to require an examination. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Absent an indication of a relationship between the claimed disorders and active service, the duty to provide an examination is not triggered. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Entitlement to service connection for left and right ear hearing loss In August 2013, VA denied service connection for bilateral hearing loss. The Veteran disagreed with the decision and perfected this appeal. He contends that he has hearing loss related to in-service noise exposure. In October 2018, the Board denied entitlement to service connection for bilateral hearing loss based on a finding that the Veteran did not have a bilateral hearing loss disability for VA purposes. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2020 Memorandum Decision, the Court vacated the Board's decision and remanded the matter for further action. Specifically, for the Board to determine whether, given the Veteran's statements as to worsening hearing loss, a more contemporaneous medical examination was necessary. In October 2020, the Board remanded the issue for additional examination and opinion. For VA purposes, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Personnel records show the Veteran worked as an amphibious track crewman and his reports of in-service noise exposure appear consistent with his military duties. In-service acoustic trauma is established. Service treatment records show that on audiometric testing at enlistment in February 1976, puretone thresholds at 500, 1000, 2000, 3000, and 4000 Hertz were: 25, 5, 0, 0, and 0 (right ear); and 5, 0, 0, 0, and 0 (left ear). On audiometric testing at separation in January 1979, puretone thresholds at 500, 1000, 2000, 3000, and 4000 Hertz were: 10, 5, 0, 0, and 10 (right ear); and 15, 15, 0, 0, and 0 (left ear). A hearing loss disability for VA purposes was not shown during active service nor does the evidence show it manifest to compensable degree within one year following discharge from active service. The Veteran underwent a VA hearing loss examination in October 2012. Audiometric and speech discrimination testing did not show a hearing loss disability for VA purposes in either ear. The examiner noted normal hearing thresholds in both ears at enlistment and separation and stated that any hearing loss was less likely as not related to or caused by his military noise exposure. The examiner also provided a positive etiology opinion concerning tinnitus. In support, she stated that comparison of the enlistment and separation physicals showed a significant threshold shift in the left ear at 1000 Hertz. The Veteran most recently underwent a VA hearing loss examination in December 2020. Audiometric testing showed hearing loss in both ears for VA purposes. The examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was related to active service or events therein to include noise exposure. In support, she stated that there was no significant permanent shift in hearing thresholds beyond test variability from entrance to separation, which is objective evidence of no permanent auditory damage on active duty from conceded noise. There were no complaints or treatment for decreased hearing in the records or at separation. The examiner further stated that auditory damage and hearing loss are not conceded based on noise alone and there must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology. The evidence was against nexus in this case. On review, the December 2020 VA examiner based the negative opinion in large part on the absence of any significant permanent shifts in hearing during service. The October 2012 VA examiner, however, found there was a significant threshold shift in the left ear at 1000 Hertz. Considering this, the Board finds the evidence in equipoise as to whether current left ear hearing loss is related to in-service noise exposure. With resolution of reasonable doubt, service connection for the left ear is warranted. See 38 C.F.R. § 3.102. Regarding current right ear hearing loss, the record contains a negative etiology opinion. The VA opinion was based on review of the record, physical examination, and supported by adequate rationale. The Board does not find probative evidence to the contrary. In making this determination, the Board acknowledges the Veteran's contentions but as discussed, he is not competent to provide a medical etiology opinion. The Veteran's lay statements are insufficient to establish a nexus to active service. The preponderance of the evidence is against the claim for the right ear and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. The claim of entitlement to service connection for the right ear is denied. Entitlement to service connection for a back disorder In August 2013, VA denied service connection for back arthritis. The Veteran disagreed with the decision and perfected this appeal. In a statement received in March 2017, the Veteran appears to relate his back problems to heavy lifting (i.e., lifting the hood on top of the AmTrac). In a Form 21-526EZ received in April 2017, he claimed back problems from driving the AmTrac. Service treatment records are negative for any complaints or findings pertaining to the back. On separation examination in January 1979, the Veteran's spine was reported as normal on clinical evaluation. Private records show the Veteran was hospitalized in October 2011 following a 15-foot fall from a ladder. Admission diagnosis included T11-T12, L1 anterior wedge compression fracture. A December 2011 VA record notes the Veteran's report that he suffered a back injury "when cutting limbs." Private records dated in February 2012 note complaints of back pain which started 4 months prior after he fell off a ladder. X-rays of the lumbar spine showed compression deformities in the bodies of L1 and L2. Both fractures were probably old, but there were no films for comparison. X-rays dated in May 2012 showed healing L1 and L2 compression fractures without significant loss of height. A May 2012 MRI showed the compression fractures as well as chronic degenerative changes, greatest at L4-L5 with a mild to moderate diffuse disk bulge and mild bilateral facet joint arthropathy resulting in moderate bilateral foraminal narrowing at this level. Evidence of record shows disability of the lumbar spine namely, compression fractures and degenerative arthritis. While service records are negative for any complaints or findings of a chronic back disorder, the Veteran is competent to report that he engaged in heavy lifting during service. Layno v. Brown, 6 Vet. App. 465, 470 (1994). His reports appear consistent with the circumstances of his service and thus, an in-service event is arguably established. On review, medical evidence shows the compression fractures occurred following a fall from a ladder when the Veteran was cutting tree limbs in October 2011. Regarding lumbar spine degenerative arthritis, this was not noted during active service and there is no indication it manifested to a compensable degree within one year following discharge from active service. The Board has carefully considered the Veteran's assertions that his back disorder is related to military duties (heavy lifting and/or driving the AmTrac). As set forth above, the Veteran's unsupported lay statements are insufficient to establish nexus and the record does not contain any probative evidence indicating his back disorder is related to active service or events therein. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claim is denied. Entitlement to service connection for type 2 diabetes, heart disorder, stomach disorder and bilateral vision disorder In August 2013, VA denied service connection for type 2 diabetes, heart condition, stomach condition to include abdominal pains, and diabetic retinopathy and cataracts claimed as vision problems. The Veteran disagreed with the decisions and perfected this appeal. He contends that his claimed disorders are related to exposure to contaminated water while he was stationed at Camp Lejeune. Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 providing a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. The amendment defines "contaminants in the water supply" as the volatile organic compound trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953 and ending on December 31, 1987. In order to qualify for presumptive service connection under these provisions, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under the new provision 38 C.F.R. § 3.309(f), (i.e., adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin's lymphoma, and Parkinson's disease), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. The rulemaking applies to claims received by or pending before VA on or after March 14, 2017. See 82 Fed. Reg. 9,4173-9,4185 (January 13, 2017). The Veteran had active service at Camp Lejeune during the relevant period and he is presumed to have been exposed to contaminants in the water supply. 38 C.F.R. § 3.307(a)(7)(iii). His claimed disorders, however, are not listed at 3.309(f) and presumptive service connection is not warranted. Notwithstanding, service connection for a disability claimed as due to contaminated water at Camp Lejeune may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). Prior to finalizing the presumptive regulations, the Veterans Benefits Administration referred claims based on exposure to contaminants to the Veterans Health Administration for subject matter expert review in certain situations (e.g., when the Veteran had a chronic disease recognized for healthcare purposes under 38 C.F.R. § 17.400). The conditions denied herein are not on that list. Type 2 diabetes Service treatment records are negative for any complaints or treatment for diabetes. On separation examination in January 1979, the Veteran's endocrine system was reported as normal on clinical evaluation. Urinalysis was negative for sugar. Medical evidence shows a current diagnosis of type 2 diabetes, but post-service records contain inconsistent information concerning onset. For example, a June 2011 VA record indicates the Veteran was a known diabetic since 1985. In August 2011, he reported that he was "diagnosed with unknown type of diabetes in ? 1980s 'when I was in the [m]ilitary' (1970s) and when seeing a [private doctor] in 1982." Impression was "[t]ype 2 diabetes (probably), longstanding, with really unknown control." In March 2012, he reported that he had diabetes in 1979 when he was drinking contaminated water at Camp Lejeune. A September 2017 private record notes a history of diabetes since 1992. On review, diabetes did not begin during active service and the record does not contain credible evidence showing that it manifested to a compensable degree within one year following discharge from active service. In making this determination, the Board acknowledges the Veteran's contentions that he had diabetes in 1979 presumably while on active duty. Again, this is not shown in the service records and the Veteran is not competent to diagnose this disorder. To the extent he may have been diagnosed with diabetes at some point during his period of Reserve service, he does not contend nor does the record suggest that it was incurred during a period of active duty for training. The fact that he may have taken diabetic medication while serving in the IRR in an inactive status does not establish onset during service. The record contains no probative evidence indicating that the Veteran's diabetes is otherwise related to active service or events therein, to include exposure to contaminated water. As set forth above, the Veteran's unsupported lay statements are insufficient to establish nexus. He has submitted no medical statements or literature in support of this theory, and diabetes is not listed as a covered illness for purposes of hospital care and medical services for Camp Lejeune Veterans. See 38 C.F.R. § 17.400. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claim is denied. Heart disorder Service treatment records are negative for any complaints or findings of a heart disorder. On separation examination in January 1979, the Veteran's heart was reported as normal on clinical evaluation. Chest x-ray was within normal limits. In an undated questionnaire for Camp Lejeune claimants, the Veteran reported having chest pain and an abnormal heartbeat in the 1980s that he believed was related to contaminated water exposure. A June 2011 VA record documents the Veteran's report that he has chest pain related to a motor vehicle accident in 1999. A May 2014 private discharge summary notes a past history of myocardial infarction. A June 2017 VA record notes on and off chest pain due to a truck accident in 2002. Private records dated in March 2018 show complaints of chest pain, again attributed to an old chest injury in a 1999 accident. The physician noted he did an EKG which was abnormal, and the Veteran was referred to a cardiologist, but he never went. Private records include discharge instructions for acute myocardial infarction and show the Veteran received patient education on "after heart catheterization" and "heart attack" in December 2020. In April 2021, he received patient education for "chest pain." Given the foregoing, the Board finds evidence of a current heart disorder, to include chest pain. There is, however, no evidence of a chronic heart disorder during active service and the record does not contain credible evidence showing that a cardiovascular disorder manifested to a compensable degree within one year following discharge. In making this determination, the Board acknowledges the Veteran's contentions that he experienced chest pain and abnormal heartbeat in the 1980s. While the Veteran is competent to report his symptoms, he is not competent to diagnose a heart disorder. The Board further notes that this statement contradicts information in the medical records which suggests chest pain beginning following a post-service motor vehicle accident in the late 1990s. The record contains no probative evidence indicating that any heart disorder, to include chest pain, is otherwise related to active service or events therein to include exposure to contaminated water. As set forth above, the Veteran's unsupported lay statements are insufficient to establish nexus. He has submitted no medical statements or literature in support of this theory, and cardiovascular disease is not listed as a covered illness for purposes of hospital care and medical services for Camp Lejeune Veterans. See 38 C.F.R. § 17.400. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claim is denied. Stomach disorder Service treatment records show the Veteran was seen in April 1976 with complaints of abdominal pain. Impression was possible venereal disease, infection of foreskin. A chronic stomach disorder was not shown and on separation examination in January 1979, the Veteran's abdomen and viscera were reported as normal on clinical evaluation. In April 2012, the Veteran reported that he has stomach aches all the time and his abdominal pains are serious. While the Veteran has not specifically identified the stomach disability he is claiming, it is noted that post-service records show a diagnosis of gastroesophageal reflux disease and the Veteran is prescribed Ranitidine HCL for his stomach. Further, the Veteran is competent to report stomach pain and pain without a diagnosis can constitute a current disability if the pain results in functional impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Notwithstanding, there is no evidence of a stomach disorder during active service or for many years thereafter. The record also does not contain probative evidence indicating that any stomach disorder is otherwise related to active service or events therein to include exposure to contaminated water. As set forth above, the Veteran's unsupported lay statements are insufficient to establish nexus. He has submitted no medical statements or literature in support of this theory, and stomach pain is not listed as a covered illness for purposes of hospital care and medical services for Camp Lejeune Veterans. See 38 C.F.R. § 17.400. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claim is denied. Bilateral vision disorder to include diabetic retinopathy and cataracts Service treatment records are negative for any complaints or treatment related to the eyes. On separation examination in January 1979, evaluation of the eyes, ophthalmoscopic, pupils, and ocular mobility were all reported as normal. Distant vision was 20/20 on the right and 20/25 on the left. The examiner noted defective distant vision not considered disabling. The Veteran underwent a VA eye examination in October 2012. The claims folder was not available for review. Diagnosis was mild nonproliferative diabetic retinopathy and cataracts both eyes. The examiner noted that the Veteran was on diabetes medication while in the Reserves. The examiner stated that diabetic retinopathy was most likely caused by or a result of diabetes, and that cataracts was at least as likely as not to have been caused by or resulted from diabetes. The following rationale was provided: Many systemic diseases can cause cataracts including diabetes mellitus. "Sugar" cataracts are cortical or posterior subcapsular opacities that occur earlier in diabetic patients than in age-matched controls, progress rapidly, and are related to poor glucose control more than duration of disease. Cataracts are 1.6 times more common in people with diabetes than in those without diabetes, according to the CDC, 1991 Guide for Primary Care Practitioners. The Veteran[']s cataracts have not affected his visual acuity in an adverse manner at this time. In February 2013, the VA examiner reviewed the claims folder. He stated that the claimed condition was at least as likely as not incurred in or caused by service. He also stated that the conditions were caused by diabetes and provided the same opinion as set forth above. Subsequent private records show continued treatment for retinopathy and other eye disorders to include laser surgery. Despite the pending appeal, the Veteran filed a supplemental claim in October 2019 and additional examination was conducted in January 2020. The Veteran reported decreased vision in both eyes for years and that he has had both laser and regular surgery. Diagnoses were proliferative diabetic retinopathy, combined cataracts, ocular hypertension, and dry eyes. There were no findings to support a diagnosis of maculopathy in either eye. The examiner opined that the Veteran's bilateral retinopathy was at least as likely as not incurred in or caused by the retinopathy during service. After review of the records, the examiner noted that the Veteran had many opportunities to have his eyes examined but either declined appointments or did not show for appointments. The chart also showed many instances where the Veteran admitted to not keeping blood glucose under good control. All the Veteran's VA medical records were reviewed and considered when rendering an opinion. Specific emphasis was given to the medical records that were listed as well as the statement from the Veteran and the findings on examination. On review, there is no evidence of a vision disorder, to include retinopathy or cataracts, during active service. To the extent the Veteran had defective distant vision at separation, this is a refractive error and there is no evidence of superimposed injury nor does the Veteran contend as such. Refractive errors are considered congenital defects and not compensable disabilities for VA purposes. 38 C.F.R. §§ 3.303(c), 4.9. VA regulations specifically prohibit service connection for refractive error of the eye unless such defect was subjected to a superimposed disease or injury which created additional disability. VAOPGCPREC 82-90; 55 Fed. Reg. 45,711 (1990). Medical evidence of record indicates that the Veteran's claimed retinopathy and cataracts are due to his diabetes. As discussed, service connection for diabetes is denied herein and thus, there is no basis for secondary service connection. See 38 C.F.R. § 3.310. The Board acknowledges that the February 2013 VA opinion indicates that the claimed conditions were due to service. Review of the rationale makes clear, however, that the examiner was relating the conditions to diabetes. The Board also acknowledges the recent 2020 opinion which relates the Veteran's current retinopathy to retinopathy during service. On review, this opinion appears to be based on inaccurate facts and is not considered probative. Reonal v. Brown, 5 Vet. App. 458 (1993) (a medical opinion based on an inaccurate factual premise is not probative). That is, there is no evidence showing that the Veteran had retinopathy during his period of active service. To the extent this is based on the Veteran's self-report that he took diabetes medications during his period of Reserve service, this is not sufficient to support in-service onset or findings of retinopathy. The documents referenced in the opinion appear to be post-service records. Further, it is unclear why opinions were requested on this issue and the requirements for additional opinion are not met. See 38 C.F.R. § 3.159(c)(4). Finally, the record does not contain any probative evidence indicating that the claimed vision disorders are related to contaminated water at Camp Lejeune. As set forth above, the Veteran's unsupported lay statements are insufficient to establish nexus. He has submitted no medical statements or literature in support of this theory, and vision disorders are not listed as a covered illness for purposes of hospital care and medical services for Camp Lejeune Veterans. See 38 C.F.R. § 17.400. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claim is denied. REASONS FOR REMAND Entitlement to service connection for a headache disorder The Veteran contends he has headaches related to exposure to contaminated water at Camp Lejeune. In June 2013, VA requested a subject matter expert opinion on this issue. In June 2013, a VA examiner reviewed the record and provided a negative etiology opinion. The examiner noted that while the Veteran served at Camp Lejeune, the record was silent regarding a diagnosis or treatment for headaches. Since there was no diagnosis of headaches, no such diagnosis could be attributed to exposure to contaminated water. Private records dated in September 2014 include a diagnosis of headache syndromes. A February 2015 record notes complaints of headache in connection with acute sinusitis. In October 2018, the Board denied service connection for headaches. The Veteran appealed this decision to the Court. In the July 2019 Appellant Brief, the attorney argued that the June 2013 opinion was inadequate for multiple reasons it was overly narrow, it failed to discuss whether the Veteran has aplastic anemia which is on the presumptive list at 38 C.F.R. § 3.309(f) and its symptoms include headaches, and that it did not address aggravation in that cataracts can cause eye strain and headaches. In February 2020, the Court vacated the Board's decision as to this issue and remanded the matter for further development consistent with the decision. The Court concluded that one argument merits remand and it expressed no opinion on the other arguments. Specifically, the Court agreed that the scope of the June 2013 opinion was too limited, or at least the Board did not explain why it was not. That is, the opinion addressed only whether the Veteran's headaches were related to exposure to contaminated water at Camp Lejeune. The Court directed that on remand, the Board must explain why such a narrow opinion is adequate, and if it cannot do so, the appellant should be provided with a more comprehensive examination. Regarding the remaining arguments, the Veteran has not filed a claim of entitlement to service connection for aplastic anemia. The appellant is advised that if he wishes to file a claim for service connection for this disorder, he must do so on the prescribed form. Second, service connection for cataracts is denied herein and there is no basis for secondary service connection. On review, there is medical evidence suggesting a diagnosis of headaches during the appeal period and the Veteran is competent to report that he experiences headaches. Considering the Memorandum Decision, the Board finds that additional examination is necessary. Entitlement to TDIU In October 2020, the Board inferred and remanded the issue of entitlement to TDIU. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran does not meet the schedular criteria for TDIU at any time during the appeal period. See 38 C.F.R. § 4.16(a). As indicated, the issue of entitlement to service connection for a headache disorder is remanded herein. The disposition of this issue may affect the claim for TDIU. Thus, the TDIU issue is deferred pending the completion of the development requested herein. Harris v. Derwinski 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his claimed headaches. The examiner must review the claims file. The examiner is requested to identify any headache disorder present at any time since April 2012. The examiner should specifically consider the September 2014 finding of headache syndromes as well as the Veteran's lay reports of headaches throughout the appeal period. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to opine whether it is at least as likely as not that any headache disorder is related to active service or events therein, to include exposure to contaminated water at Camp Lejeune. The examiner is advised that a negative opinion cannot be based solely on the fact that headaches are not on the list of diseases that are presumptively associated with exposure to contaminants in the water supply at Camp Lejeune. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). 2. Thereafter, readjudicate the claims of entitlement to service connection for a headache disorder and for TDIU. If the Veteran does not meet the schedular requirements under 38 C.F.R. § 4.16(a), consider whether extraschedular referral is warranted. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Carsten, 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.