Citation Nr: 21040708 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 15-19 087 DATE: July 6, 2021 ORDER Entitlement to service connection for bilateral eye peripheral vision loss and photophobia as due to service-connected traumatic brain injury (TBI) is granted. REMANDED Entitlement to service connection for a bilateral eye disability, other than loss of peripheral vision and photophobia, is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a bilateral lower extremity neurologic disability, to include neuropathy and radiculopathy, is remanded. Entitlement to service connection for a bilateral upper extremity neurologic disability, to include neuropathy and radiculopathy, is remanded. Entitlement to service connection for a neck disability is remanded. FINDING OF FACT The record evidence shows that the Veteran's bilateral eye peripheral vision loss and photophobia are a result of his service-connected traumatic brain injury (TBI). CONCLUSION OF LAW The criteria for service connection for bilateral eye peripheral vision loss and photophobia have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1976 to June 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran testified before a Veterans Law Judge (VLJ) and a transcript of the hearing is of record. The VLJ subsequently retired from the Board. The Veteran was provided an opportunity to attend another Board hearing. He indicated in August 2019 and in May 2021 indicated that he did not wish to appear for another Board hearing. As such, the Board will proceed with adjudication of these claims. This matter was remanded in October 2019 for further development. In determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran originally filed claims for pinguecula and conjunctivitis. The claims file contains additional diagnoses for loss of peripheral vision, photophobia, retinopathy, epiphora, and right eye intraocular hemorrhage. As a result, the Board expanded the claim to include this diagnosis. Id. Similarly, as will be discussed below, he has been diagnosed with both peripheral neuropathy and radiculopathy of the extremities. As a result, the Board has expanded his claim to reflect these differing diagnoses. Service Connection 1. Entitlement to service connection for bilateral eye disabilities. The Board finds that the evidence supports granting the Veteran's claim of service connection for bilateral eye peripheral vision loss and photophobia as due to service-connected TBI. The Veteran seeks service connection for bilateral eye disabilities, to include as secondary to service-connected disabilities. Current disabilities of bilateral photophobia and loss of peripheral vision are established by way of a February 2020 VA examination. Additionally, service connection is in effect for a TBI. Therefore, the first and second elements of service connection are met. What remains is whether there is a medical nexus between the current disability and active service. In February 2020, a VA examiner opined that the Veteran's bilateral photophobia and loss of peripheral vision were etiologically related to his service-connected TBI. As rationale, the examiner cited to the manifestation of the Veteran's conditions as evidenced by in-person examination and review of treatment medical records. This opinion was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The third element of service connection is met. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for bilateral photophobia and bilateral loss of peripheral vision is warranted. REASONS FOR REMAND 2. Entitlement to service connection for a bilateral eye disability, other than loss of peripheral vision and photophobia. As indicated above, service connection is now established for bilateral loss of peripheral vision and photophobia. Beyond these diagnoses, the Veteran also has diagnoses for bilateral pinguecula both nasal and temporal, bilateral conjunctivitis, bilateral early stage cataracts, bilateral epiphora, right eye intraocular hemorrhage, and retinopathy. Considering the above grant of service connection, the Board finds that, on remand an opinion should be obtained addressing whether the service-connected eye disabilities either caused or aggravated his non-service-connected eye disabilities. In addition, a clarifying opinion is warranted. In January 2020, a VA examiner explained that the Veteran suffered from epiphora which was characterized by excessive watery eyes. No discussion was provided as to the Veteran's assertions of suffering from watery and itchy eyes during service and whether such symptoms were indicative of him suffering from undiagnosed epiphora in-service. The Board finds that such an opinion should be obtained on remand. 3. Entitlement to service connection for diabetes mellitus. The Veteran seeks service connection for diabetes mellitus which he asserts manifested during service. At his Board hearing, he asserted that he suffered from an excessive desire to eat sugar while in service. He cited to this as a symptom of his diabetes mellitus manifesting in service. As rationale for this opinion, the Veteran cited to his own personal medical knowledge. Review of the record reflects that he has at least some medical training. His military occupational specialty (MOS) was a medical specialist and personnel records also specify that he worked as an ambulance attendant. Given the Veteran's testimony and the indication of at least some medical training, the Board finds that, on remand, an opinion should be obtained which addresses this matter. 4. Entitlement to service connection for GERD and for allergic rhinitis. The Veteran seeks service connection for GERD and allergic rhinitis by asserting that both conditions began during service and continued until the present. As to GERD, the Veteran testified at his Board hearing to suffering from heartburn so severe that he would wake up at nights and taste acid in his throat in-service. As evidence of the progression of his condition since service, he cited to his in-service need for only over the counter medication and his current need for a proton pump inhibitors. He indicated this progression was clear evidence of a longstanding worsening condition. As to allergic rhinitis, he testified to suffering from watery and itchy eyes, shortness of breath, wheezing, and severe sinusitis. Service treatment records confirm treatment for respiratory symptoms, sore throat, ear infections, and swollen tonsils. In January 2020, he was afforded VA examination opinions. The examiner provided a negative medical nexus opinion but did not address the significance of his reports of symptomatology in and since service and the above records. Thus, the Board finds that the January 2020 opinions are inadequate for VA purposes. The Board also finds that, on remand, addendum opinions should be obtained which address these matters. 5. Entitlement to service connection for hypertension. The Veteran asserts that he suffered from hypertension in service because of his stressful MOS as a medical specialist and working as an ambulance attendant. Service treatment records confirm that he received treatment for anxiety syndrome and he reported suffering from heart problems. Although he was afforded a VA examination opinion in January 2020, the examiner did not address his contentions regarding in-service stress, his in-service treatment for anxiety, and/or his treatment medical records and whether these could have led to his development of hypertension. Thus, the Board finds that the January 2020 opinion is inadequate for VA purposes. The Board also finds that, on remand, an opinion should be obtained which addresses these matters. 6. Entitlement to service connection for a bilateral upper extremity neurologic disability and for a bilateral lower extremity neurologic disability. The Veteran seeks service connection for bilateral upper and lower extremity neurologic disabilities. This matter was remanded for VA examination. The Veteran was afforded a January 2020 VA Diabetic Neuropathy Examination. The examiner opined that the Veteran did not suffer from diabetic neuropathy but instead only suffered from lower extremity radiculopathy. The record lacks an opinion as to the etiology of the Veteran's radiculopathy. Such an opinion is warranted because the Veteran testified at his Board hearing that he suffered from numbness, tingling, and weakness since service. Service treatment records document treatment for muscle weakness, tension, cramping, and sensitivity. He was prescribed a "balm for his limbs" in service to treat these symptoms. Thus, the Board finds that the January 2020 opinion is inadequate for VA purposes. The Board also finds that, on remand, an opinion should be obtained which addresses these matters. In addition, the January 2020 VA examiner opined that the Veteran did not suffer from upper extremity radiculopathy or neuropathy. The examiner did not explain how this finding addressed VA treatment records documenting a current diagnosis for cervical radiculopathy. This examiner also did not address a June 2013 VA diabetes mellitus DBQ which confirmed a diagnosis of neuropathy. Thus, the Board finds that the January 2020 opinion is inadequate for VA purposes. The Board also finds that, on remand, an opinion should be obtained which addresses this matter. 7. Entitlement to service connection for a neck disability. The Veteran was afforded a January 2020 VA examination opinion. The examiner provided a negative medical nexus opinion, in part, because the record did not reflect neck disability symptomatology following his in-service TBI. This examiner did not address the significance of the Veteran's reports of upper extremity numbness and pain during and after active service. The location of the Veteran's radiculopathy and his reported symptomatology suggests that he suffered a neck injury in service which continued until the present. This examiner also did not address service treatment records which document muscle weakness and pain. Thus, the Board finds that the January 2020 opinion is inadequate for VA purposes. The Board also finds that, on remand, an opinion should be obtained which addresses this matter. The RO also should obtain the Veteran's updated treatment records. The matters are REMANDED for the following action: 1. Conduct any appropriate development to obtain the Veteran's updated treatment records. 2. Thereafter, forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of any eye disabilities other than bilateral loss of peripheral vision and/or photophobia. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to identify any eye disabilities other than bilateral photophobia and/or loss of peripheral vision currently experienced by the Veteran, to include bilateral pinguecula both nasal and temporal, bilateral conjunctivitis, bilateral early stage cataracts, bilateral epiphora, right eye intraocular hemorrhage, and retinopathy. For each diagnosed eye disability, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it is related to active service or any incident of service, to include in-service treatment for blurred vision. The clinician next is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a service-connected disability caused the diagnosed eye disability. A rationale must be provided for any opinion(s) expressed. A separate opinion and rationale should be provided for each diagnosed eye disability other than bilateral loss of peripheral vision and/or photophobia currently experienced by the Veteran, if appropriate. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the Veteran has some medical training. The clinician also is advised that the lack of contemporaneous records documenting complaints of or treatment for an eye disability, alone, is insufficient rationale for a medical nexus opinion. 3. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's diabetes mellitus. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that diabetes mellitus is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the Veteran has some medical training. The clinician also is advised that the lack of contemporaneous records documenting complaints of or treatment for diabetes mellitus, alone, is insufficient rationale for a medical nexus opinion. 4. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's GERD. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that GERD is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the Veteran has reported that he experienced heartburn so severe that he would wake up at nights and taste acid in his throat in service. The clinician next is advised that the Veteran has some medical training. The clinician also is advised that the lack of contemporaneous records documenting complaints of or treatment for GERD, alone, is insufficient rationale for a medical nexus opinion. The clinician finally is advised not to review or rely upon a January 2020 VA medical nexus opinion in preparing his or her own opinion. 5. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's allergic rhinitis. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that allergic rhinitis is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the Veteran contends that he experienced watery and itchy eyes, shortness of breath, wheezing, and severe sinusitis during service. The clinician next is advised that the Veteran has some medical training. The clinician also is advised that the lack of contemporaneous records documenting complaints of or treatment for allergic rhinitis, alone, is insufficient rationale for a medical nexus opinion. The clinician finally is advised not to review or rely upon a January 2020 VA medical nexus opinion in preparing his or her own opinion. 6. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's hypertension. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension, if diagnosed, is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for hypertension, alone, is insufficient rationale for a medical nexus opinion. The clinician next is advised that the Veteran has some medical training. The clinician finally is advised not to review or rely upon a January 2020 VA medical nexus opinion in preparing his or her own opinion. 7. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's bilateral upper extremity neurologic disability and for a bilateral lower extremity neurologic disability. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to identify any neurologic disability/ies of the bilateral upper extremities and/or of the bilateral lower extremities currently experienced by the Veteran. For each diagnosed neurologic disability, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for a bilateral upper extremity neurologic disability or for a bilateral lower extremity neurologic disability, alone, is insufficient rationale for a medical nexus opinion. The clinician next is advised that the Veteran has some medical training. The clinician finally is advised not to review or rely upon a January 2020 VA medical nexus opinion in preparing his or her own opinion. 8. Forward the claims file and a copy of this REMAND to a clinician for an opinion concerning the nature and etiology of the Veteran's neck disability. If possible, this opinion should be provided by a clinician other than the clinician who provided a January 2020 medical nexus opinion. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to identify any neck disability/ies currently experienced by the Veteran. For each diagnosed neck disability, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for a neck disability, alone, is insufficient rationale for a medical nexus opinion. The clinician next is advised that the Veteran has some medical training. The clinician finally is advised not to review or rely upon a January 2020 VA medical nexus opinion in preparing his or her own opinion. 9. Readjudicate the appeal. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Burroughs, 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.