Citation Nr: 21032404 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 13-06 755 DATE: May 27, 2021 REMANDED Entitlement to service connection for a left eye disability, to include as due to a traumatic brain injury (TBI), is remanded. REASONS FOR REMAND The Veteran served in active duty service with the Army from April 2009 to April 2020 to include service with the National Guard with an active duty training period form March 2007 to July 2007. This matter is on appeal from a June 2012 rating decision. The Board remanded this appeal in December 2016, August 2018, and January 2021 for additional development. The Board finds that remand is warranted for further development. Review of the medical treatment record shows findings of convergence insufficiency; accommodative insufficiency; epiretinal membrane (ERM); photophobia; and refractive error. In an August 2018 Board decision, the Board remanded the appeal to obtain an opinion to determine if there was any diagnosed left eye disability present at any time since May 2010 to address findings of convergence insufficiency; accommodative insufficiency; epiretinal membrane (ERM); photophobia; and whether such findings were related to service. The remand also instructed an opinion on whether there was an additional disability superimposed on refractive error as well as to provide explanation or rationale if no such diagnoses were present. In a June 2019 addendum VA opinion, the examiner opined that there was no visual deficit or field defect and/or diagnosis present in the left eye; however the examiner found that previously findings or diagnoses were not present at the time of the VA examination in January 2017 and did not opine whether they were present during the period from May 2010 to January 2017. The Board remanded the appeal in January 2021 for an addendum opinion. In February 2021 the VA examiner found the Veteran since May 2010 to be diagnosed with convergence insufficiency; and accomodation insufficiency affecting both eyes "by definition"; the examiner noted the Veteran did not present with an acute left ocular injury or illness and therefore presumed the Veteran's photophobia to also be bilateral. The examiner indicated a positive etiology opinion but did not provide any specific rationale or explanation how the diagnoses related to the Veteran's active duty service. The same examiner also provided a negative etiology opinion, finding there was "no left eye only condition diagnosed" and the Veteran's history of convergence insufficiency, accomodation insufficiency and photophobia affecting both eyes were status post TBI and common findings after TBI. The examiner also did not opine on the Veteran's refractive error. The Board also notes review of the medical treatment record shows findings and assessments for status post TBI and the February 2021 VA examiner indicated the diagnoses were related to status post TBI without providing a formal opinion on whether TBI caused or aggravated the Veteran's claimed left eye disability. Given the conflicting findings made by the February 2021 opinion, the Board finds the opinion to be inadequate and remand warranted for clarification. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records relating to the Veteran's claimed left eye disability. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed left eye disability. The examiner must review the entire claims file, to include a copy of this remand, the January 2017 VA examination, June 2019 VA opinion, and February 2021 VA opinion in conjunction with the examination. Based on this review of the record, and examination if provided, the examiner should provide opinions that respond to the following: (a.) Identify each current left eye disability. If any left eye disability existed during the appeal period from May 2010 to the present but has resolved, this should be made clear. The examiner should address the May 2011 optometry visit diagnoses to include convergence insufficiency; accomodation insufficiency; epiretinal membrane; and photophobia. The examiner should also address and resolve the conflicting findings made in the February 2021 VA opinion. (b.) For each left eye disability identified, whether resolved or active, please address whether it is at least as likely as not (a probability of 50 percent or greater) that such disability is a residual of the Veteran's claimed TBI? (c.) If not a residual, whether is it at least as likely as not (a 50 percent or greater probability) that such was caused by the Veteran's TBI? (d.) Whether is it at least as likely as not (a 50 percent or greater probability) that such was aggravated by the Veteran's TBI? Aggravation in this context means the disability increased in severity beyond its normal progression. If aggravation is found, the opinion provider should indicate, to the extent possible, the approximate baseline level of disability before the onset of aggravation. (e.) If any left eye disability identified, whether resolved or active, is not caused or aggravated by the Veteran's claimed TBI, is it is at least as likely as not (a probability of 50 percent or greater) that such disability is etiologically related to the Veteran's active military service? (f.) With regard to the Veteran's claimed left eye refractive error, the examiner is also asked to offer an opinion as to whether such was subject to a superimposed disease or injury during service If so, please identify the additional disability. 3. The examiner is also advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. (a.) The examiner should provide a complete and clearly stated rationale for any opinion provided. (b.) If the VA examiner is unable to provide an opinion without resorting to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.