Citation Nr: 21032277 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-41 326 DATE: May 26, 2021 REMANDED Entitlement to service connection for an eye disability is remanded. REASONS FOR REMAND The Veteran served from October 1989 to November 1989, from January 1992 to July 1992, from September 1992 to November 1998, from December 1998 to July 1999, from July 2002 to September 2003, from October 2003 to January 2004, and from July 2006 to September 2009. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been before the Board previously. In March 2019, the Board remanded the issue on appeal for the Agency of Original Jurisdiction (AOJ) to provide the Veteran with a VA examination. Subsequently, after an August 2020 Supplemental Statement of the Case considered the record, this matter was returned to the Board for appellate consideration. The Board finds there has been substantial compliance with its prior remand directives as the Veteran was afforded a VA examination for his eye disability issue on appeal and a subsequent addendum opinion. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection requires evidence showing: (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 condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection for an eye disability. After review of the record, another remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the appellant is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran claims service connection for an eye disability. Service treatment records showed that the Veteran was diagnosed with corneal dystrophy, endothelial cornea guttata, and blurry vision. See 1/20/2017 Medical Treatment Record Government Facility, at page 54. Additionally, service treatment records showed that in November 1997, the Veteran suffered an in-service accident where plastic/fiberglass fragments from wires fell into his right eye and caused an eye trauma. Id., at page 16. After the March 2019 Board remand, the Veteran was afforded a VA examination in October 2019. During the examination, the Veteran was diagnosed with corneal guttata and diplopia. However, the examiner provided no nexus opinion. See 10/21/2019 C&P Examination. Subsequently, in July 2020, the AOJ obtained a negative addendum opinion. As rationale, the reviewing clinician stated that corneal guttata is a defect in the endothelial layer of the cornea and that it occurs in many healthy individuals in the general population. Additionally, the reviewing clinician stated that it can be caused by "significant ocular injury, which is not noted in the [Veteran's] eye records." See 7/31/2020 C&P Examination. However, the Board finds this opinion inadequate. The reviewing clinician did not directly address whether or not the above-mentioned in-service accident qualified as an ocular injury capable of causing the in-service diagnosed corneal guttata. Further, the reviewing clinician did not address whether or not the diagnosed diplopia was related to the in-service incident and/or the in-service diagnosed corneal dystrophy, endothelial cornea guttata, and blurry vision. As such, on remand, the RO should obtain an addendum opinion to determine if the above-mentioned in-service accident qualified as an ocular injury capable of causing the in-service diagnosed corneal guttata. Furthermore, the opinion must determine if the diagnosed diplopia was related to the in-service incident and/or the in-service diagnosed corneal dystrophy, endothelial cornea guttata, and blurry vision. This matter is REMANDED for the following action: Return the claims file to the examiner who conducted the July 2020 addendum VA examination and authored the opinion, if available, or provide the claims file to an appropriate specialist. A copy of this remand request should also be provided. After a review of the claims file, the reviewing clinician is asked to address the following: (a.) Compile a list of all current eye disabilities. (b.) For EACH eye disability identified on the current examination, state whether it is at least as likely as not (probability of 50 percent or more), that any of the Veteran's current eye disabilities in whole or part, had their onset in service, including as a result of the in-service incident. **In doing so, please address if the in-service accident qualified as an ocular injury capable of causing the in-service diagnosed corneal guttata. See 1/20/2017 Medical Treatment Record Government Facility, at page 16. Additionally, please address if the diagnosed diplopia is related to the in-service incident and/or the in-service diagnosed corneal dystrophy, endothelial cornea guttata, and blurry vision. See 1/20/2017 Medical Treatment Record Government Facility, at page 54.** If the July 2020 reviewing clinician is no longer available, then the claims file and the October 2019 and July 2020 examination and opinion should be forwarded to another examiner of at least equal qualifications to obtain the requested opinion. If an examination is deemed necessary to provide an adequate opinion, then one should be obtained. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). T. SHERRARD Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Fuentes, 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.