Citation Nr: 21042333 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 20-16 462 DATE: July 12, 2021 REMANDED Entitlement to a disability rating in excess of 10 percent for bilateral pterygium with dry eye syndrome is remanded. Entitlement to a disability rating in excess of 10 percent for scar is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served honorably on active duty with the United States Navy from September 1961 to September 1967. This case was most recently before the Board in June 2020, at which time the issues on appeal were remanded for additional development. Regrettably, for the reasons discussed below, another remand is necessary. In accordance with the Board's June 2020 remand instructions, additional VA treatment records were associated with the claims file. These records show that there are treatment records that are available as scanned documents in VistA Imaging but have not been associated with the claims file and are therefore unavailable for review by the Board. These records include the results of a June 2020 VA Community Care consultation at the Southwest Eye Consultants. VA treatment records also show that treatment notes from a May 2019 consultation at Evans Eyecare, notes from May 2015 Veterans Choice treatment by non-VA provider B.S., and a June 2015 note from Arizona Eyecare of Anthem were scanned into VistA Imaging. The Board notes that it does not have access to VistA Imaging, so these records must be printed from VistA and uploaded/added to the Veteran's VBMS or Virtual VA file. Remand is necessary to obtain these records, as they are relevant to the claim on appeal. Review of VA treatment records also show the Veteran has received private optometry and ophthalmology treatment from private providers through the VA Choice program. Specifically, a December 2020 treatment note shows the Veteran was approved for community care ophthalmology treatment. Additionally, the Veteran received treatment with private provider B.S., an optometrist, through the VA Choice program in 2015. Unfortunately, records of this private treatment are not available in the claims file. Therefore, remand is warranted to obtain these records. Additionally, remand is warranted to afford the Veteran another VA eye examination, as the most recent examination, completed in October 2020, did not include an evaluation of the Veteran's well-documented eye scarring, as requested by the Board in its June 2020 remand. Finally, the Board finds that adjudication of the Veteran's increased rating claims could impact his total disability rating; therefore, the issue of entitlement to a TDIU is inextricably intertwined with the claims on appeal. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA medical treatment records, to include records from April 2021 to the present, and records of any private community care ophthalmology or optometry treatment received through the VA Choice program, to include treatment noted in May and June 2015 and December 2020. 2. Obtain VA eye treatment records that have been scanned into VistA Imaging but are not associated with the Veteran's claims file, including the results of a June 2020 VA Community Care consultation at the Southwest Eye Consultants, a May 2019 consultation at Evans Eyecare, notes from May 2015 Veterans Choice treatment by non-VA optometrist B.S., and a June 2015 note from Arizona Eyecare of Anthem. The Board reminds the AOJ that the Board does not have access to VistA Imaging, so these records must be printed from VistA and uploaded/added to the Veteran's VBMS or Virtual VA file. 3. Then, schedule the Veteran for a VA eye examination to determine the current severity of his service-connected bilateral pterygium and scarring. The examination must be completed by a licensed optometrist or ophthalmologist. The electronic claims file must be made available to the examiner for review in conjunction with the examination. All necessary tests should be performed, and the results reported. The examiner should specifically identify the disease, injury, or other pathologic process responsible for any visual impairment found, including any visual field loss, and describe in detail all pertinent symptomatology and findings. Any appropriate Disability Benefits Questionnaire (DBQ) should be filled out for this purpose, including a scars and disfigurement DBQ. The examiner should consider all applicable rating criteria during the appeal period (including the versions of the eye rating criteria effective prior to and effective from May 13, 2018). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran's bilateral pterygium with dry eye syndrome and discuss the effect of the disability on any occupational functioning and activities of daily living. The examiner is also asked to opine as to whether any visual impairment, including the visual field impairment documented during the April 2018 and October 2020 VA examinations, could be attributable to the Veteran's bilateral pterygium with dry eye syndrome. The examiner should identify the type of disfigurement caused by the Veteran's bilateral pterygium and/or the surgical procedures to remove them. This includes a measurement of its approximate size, as well as individual and combined total areas of the pterygium and any related scarring. In this regard, the Board notes that while a pterygium may not be considered "scarring" in the medical sense of the term, VA regulations treat them as such for the purpose of evaluating and rating the severity of the disability. Unretouched color photographs of the affected areas should be obtained. See Diagnostic Code 7800, Note (5). The examiner is advised that the Veteran is competent to report symptoms, and his reports must be considered in formulating opinions. A clear rationale for any opinion expressed would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Then, readjudicate the appeal, including the claim for a TDIU. If the benefits sought remain denied, issue a supplemental statement of the case to the Veteran and his representative and return the case to the Board. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. T. Raftery, 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.