Citation Nr: 21042068 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 19-22 363A DATE: July 11, 2021 REMANDED Entitlement to service connection for a bilateral eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1966 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a bilateral eye disorder is remanded. The Veteran contends that his bilateral eye disorder is due to Agent Orange exposure. See Correspondence (November 2016). Alternatively, the Veteran asserts that his eye disorder is due to sand, dust, and wind exposure during his service in Vietnam as a helicopter engineer. See NOD (May 2018). He reported that he had styes in his eyes during that time. See NOD (May 2018). The Board finds that remand is warranted to attempt to obtain relevant medical records and to provide the Veteran with a VA examination. First, remand is required to attempt to obtain relevant medical records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records. 38 C.F.R. § 3.159(c)(2). This duty to assist also includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). In a March 2017 statement, the Veteran listed several locations that apparently related to this claim for benefits: a Houston, Texas hospital that he went to in July 2011; the VA Medical Center in Albuquerque in May, June, or July 2010; and Fort Miley in San Francisco, California from 2011 to 2013. See VA 21-4138 Statement in Support of Claim (March 2017). Of record are VA medical records from Reno, Nevada dated from 2013 to 2014, from Albuquerque, New Mexico dated in 2010, and from San Francisco, California dated in 2010. See CAPRI (February 2017). There were not attempts to obtain clarification or authorization from the Veteran regarding the private hospital records in Houston, Texas. Additionally, it isn't clear that we have the entirety of the relevant VA records. Furthermore, the Veteran submitted private treatment records from UC Davis Health System. See Medical Treatment Record (October 2016). The medical record indicated the Veteran should return in one year. No follow-up records are associated with the claims file. These, and any other relevant records, should be obtained on remand. Second, remand is required for a VA examination and opinion. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Even if a veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide exposure, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Here, there are diagnoses of bilateral cataracts. See Medical Treatment Record (October 2016). The Veteran served in Vietnam from March 1967 to March 1968 and was thus exposed to Agent Orange. See Military Personnel Record (October 2015); 38 U.S.C. § 101(29)(A); 38 C.F.R. § 3.307(a)(6)(iii). Additionally, the Veteran has asserted he was exposed to sand, dust, and wind while serving as a helicopter engineer. See NOD (May 2018). The Veteran's service personnel records confirm a military occupational specialty of helicopter mechanic. See Certificate of Release or Discharge From Active Duty (October 2016). Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain all of the Veteran's VA treatment records from Reno, Nevada, Albuquerque, New Mexico, and San Francisco, California from initial treatment to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for his eye symptoms/disorders, to include the UC Health Davis System and for the hospital in Houston, Texas that he went to in July 2011. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for a bilateral eye disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed eye disorder. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to: Whether the Veteran's bilateral eye disorder at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease, to include a) Agent Orange exposure, despite it not being a presumptive disease, or b) exposure to wind, dirt, and sand while a helicopter engineer in Vietnam. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. 4. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.