Citation Nr: 21041768 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-24 984A DATE: July 10, 2021 REMANDED Service connection for a vision disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2003 to July 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in June 2019 for further development. Service connection for a vision disorder is remanded. The Board remanded this issue so that the Veteran could undergo a VA examination for the purpose of determining the nature and etiology of the Veteran's vision disorder. The Veteran underwent a VA examination in November 2019. In a June 2021 Brief, the Veteran argued that the examination was inadequate in so far as the negative nexus opinion was based on an inaccurate factual premise. The Board agrees. The examiner stated that "Review of the records indicates a diagnosis of right eye amblyopia prior to service." Review of the service treatment records reflects that the Veteran's vision in his right eye was 20/90 (corrected to 20/50), compared to the left eye (which was 20/25). However, there was no diagnosis of amblyopia (lazy eye). The service treatment records reflect that the Veteran sustained an injury to his left eye in April 2006. The November 2019 VA examiner stated that "the service injury was superficial and to the left eye. There is a note in the military record stating his right eye was lazy/amblyopic. His right eye exotropia is the result of that amblyopia and not the result of the injury he sustained to the left eye while in service." The Board notes that this is an inaccurate/incomplete portrayal of the service treatment records. The service treatment records reflect that the Veteran sustained an injury to his left eye in April 2006. At the time of the injury, the treatment report reflects that the Veteran "denies [prior medical history] of ocular trauma but states a [sic] OS [left eye] amblyopia." A May 2008 Report of Medical Assessment states that the Veteran "had superficial left eye injury, treated by ophthalmologist. [Veteran] now states he had lazy right eye. Fully documented in medical record." However, this is contradicted by the Veteran in his May 2008 Report of Medical History, in which he stated "I was poked in the eye while working on the boat in April 2006. Developed a 'lazy eye' after the incident." The May 2008 examiner summarized by stating that the Veteran had an "eye injury in 2006, superficial abrasion. [Veteran] states he now has 'lazy eye.'" The service treatment records are inconsistent in so far as the May 2008 examiner stated that the Veteran injured his left eye in April 2006, and that he "now states he had a lazy right eye." This is in conflict with the April 2006 treatment report stating that the Veteran had left eye amblyopia, and the May 2008 Report of Medical History in which the Veteran reported that he was poked in the eye in April 2006 and that he developed a lazy eye after the incident. The record is further complicated by a December 2017 report from Dr. T.J.M. in which he states that the Veteran was hit by a piece of rebar in 2005 (he didn't say which eye). He stated that "over the next several months, [the Veteran] noticed a worsening outward drifting of his right eye." Dr. T.J.M. stated that it does not cause double vision, but it does prevent the Veteran from being able to use his eyes as well together as he could prior to the injury in 2005. The November 2019 VA examiner appears to have based his opinion on the May 2008 VA examiner who stated that the Veteran "had superficial left eye injury, treated by ophthalmologist. [Veteran] now states he had lazy right eye." He did not address the April 2006 treatment report that specifically noted left eye amblyopia at the time of the left eye injury. The examiner likewise failed to note the Veteran's contentions in the May 2008 Report of Medical History regarding having a lazy eye following the April 2006 injury to his left eye. Consequently, the Board finds that a new VA examination is warranted. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination for his vision disorder. The examiner must review the claims file. 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(s) below. The examiner is asked to provide a response to the following: Regarding the left eye, is the Veteran's eye/vision disability at least as likely as not related to service, including an April 2006 left eye injury in which amblyopia was noted at the time of the injury, and which was again reported by the Veteran in his May 2008 Report of Medical History? Provide a rationale to support the opinion(s). Regarding the Veteran's right eye, did the disability clearly and unmistakably (undebatable) preexist the Veteran's service? If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to service. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Prem, 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.