Citation Nr: 21041907 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-43 243 DATE: July 10, 2021 REMANDED 1. Entitlement to service connection for a left eye disability, other than exotropia, is remanded. 2. Entitlement to service connection for a right eye disability, other than exotropia, is remanded. 3. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected prostate cancer, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from March 1975 to March 1978 and from August 1981 to September 1998. These matters are before the Board of Veterans' Appeals (Board) on appeal of an April 2015 Department of Veterans Affairs (VA) rating decision. In March 2021, a virtual hearing was held before the undersigned; a transcript is in the record. [A February 2020 rating decision had awarded service connection for exotropia, rated 0 percent effective November 26, 2018.] 1. 2. Entitlement to service connection for left and right eye disabilities other than exotropia. While a February 2020 rating decision awarded service connection for exotropia, to include diplopia, as secondary to service-connected Parkinson's disease, the Board observes that VA treatment records for the pendency of this appeal show diagnoses of various other (than exotropia) acquired eye conditions, to include suspect glaucoma, cataracts, and dry eye. See November 2015, December 2019, and December 2020 VA treatment records. On February 2020 VA eye examination, only exotropia was diagnosed. The examiner did not address the various other diagnosed eye conditions noted in his VA treatment records. In June 2021 correspondence, the Veteran reported he underwent an eye examination at McGuire VA hospital on April 10, 2021, which indicates that pertinent records that are of record are outstanding (and the record for review before the Board in this matter is incomplete). Development for the outstanding treatment records is necessary; VA treatment records are constructively of record. There is conflicting evidence in the record regarding the Veteran's eye disability diagnosis and the etiology of all his eye disabilities shown during the pendency of the appeal. A medical advisory opinion to clarify the diagnoses/reconcile the conflicting evidence and ascertain the etiology of the diagnosed eye disabilities is necessary. 3. Entitlement to service connection for hemorrhoids. Initially, the Veteran contended that his hemorrhoids are related directly to his service and complaints therein. His service treatment records (STRs) show that he was seen for complaints of burning with bowel movement and pain. See October 1975 clinical record. An alternative theory of entitlement has been raised by the record (that the Veteran's hemorrhoids are secondary to treatment he received for his service-connected prostate cancer residuals. In a November 2014 statement, his private provider noted the Veteran reported anorectal pain and rectal bleeding since receiving radiation therapy for prostate cancer; anoscopy revealed somewhat enlarged internal hemorrhoids with inflammation. The provider opined the bleeding could be hemorrhoidal or from radiation proctitis (noting he did not see any definite radiation effects although the view was limited). At the March 2021 hearing, the Veteran testified that his hemorrhoids worsened after he was treated for prostate cancer and bled more. In a May 2021 statement in support of his claim, a private provider noted the Veteran had been under care for prostate cancer and was treated with radiation therapy. The provider noted he has been having some issues with bleeding from the rectum, which is "believed" to be from hemorrhoids. The provider opined there is a "distinct possibility" that the radiation therapy "could be" playing a role in the bleeding hemorrhoids. The May 2021 private opinion is inadequate for rating purposes as it is stated in speculative terms ("believed," "distinct possibility," and "could be"). The Veteran has not been afforded a VA examination to determine the etiology of his hemorrhoids. Considering the state of the medical evidence of record, the low threshold standard for when a VA examination (to secure a medical advisory opinion) is necessary has been met. Accordingly, development for a medical opinion is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following: 1. Ask the Veteran to identify the provider(s) of all evaluations and treatment he has received for his hemorrhoids since service (records of which are not already in the record) and to submit authorizations for VA to obtain complete records of any private evaluations or treatment. Secure for the record complete clinical records of the evaluations and treatment from all providers identified. If any private records identified are not received pursuant to a VA request, the Veteran should be so notified and advised that ultimately, it is his responsibility to ensure that private records are received Also, obtain all outstanding (any not already associated with the record), updated to the present, records of the Veteran's VA evaluations and treatment for his eyes and for hemorrhoids. 2. Then, arrange for the Veteran's record to be forwarded to an appropriate clinician for review and an advisory medical opinion regarding the etiology of each of his currently diagnosed eye disorders other than exotropia. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should: (a.) Identify by diagnosis each eye disability found or shown by the record during the pendency of this claim. Regarding all eye pathology/impairment found on examination/shown by the record during the pendency of this claim, with respect to each separate entity identified, indicate whether it is a refractive error or congenital/developmental abnormality in nature, or represents acquired eye pathology/disability (to include any superimposed on a refractive error or congenital/developmental defect by injury or disease in service). (b.) Identify the likely etiology for each eye disability other than exotropia diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that it is etiologically related to the Veteran's service. (c.) If an acquired eye disability is determined to be unrelated to the Veteran's service, opine further whether it is at least as likely as not that the disability was caused or aggravated by (increased in severity due to) the Veteran's service-connected disabilities, to include Parkinson's Disease and/or obstructive sleep apnea. [The opinion must address aggravation.] (d.) If a service-connected disability did not cause, but aggravated, an acquired eye disability diagnosed, specify, to the extent possible, the degree of disability (symptoms and/or impairment) that resulted from such aggravation. (e.) If a diagnosed acquired eye disability (other than exotropia) is determined to not have been incurred in service or caused or aggravated by a service-connected disability, identify the etiology for such disability that is considered to be more likely (and explain why that is so). All opinions must include rationale that cites to supporting factual data and medical principles. 3. Also, arrange for the Veteran's record to be forwarded to an appropriate clinician for review and an advisory medical opinion regarding the etiology of his hemorrhoids. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should: (a.) Identify the likely etiology for the Veteran's hemorrhoids. Specifically, is it at least as likely as not (a 50% or greater probability) that they are etiologically related directly to his service, to include his rectal complaints therein? (b.) If the hemorrhoids are determined to be unrelated to his service, opine further whether it is at least as likely as not that such disability was caused or aggravated by (increased in severity due to) the Veteran's service-connected prostate cancer (and its treatment with radiation). [The opinion must address aggravation.] (c.) If the Veteran's service-connected prostate cancer and its treatment did not cause, but aggravated, his hemorrhoids, specify, to the extent possible, the degree of disability (symptoms and/or impairment) that resulted from such aggravation. (d.) If a hemorrhoid disability is determined to not have been incurred in service or caused or aggravated by a service-connected disability, identify the etiology for the hemorrhoid disability that is considered to be more likely (and explain why that is so). All opinions must include rationale. Specifically comment on (express agreement or disagreement with) the May 2021 opinion by a private provider. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.