Citation Nr: 21056926 Decision Date: 09/14/21 Archive Date: 09/14/21 DOCKET NO. 16-58 462A DATE: September 14, 2021 ORDER A rating higher than 10 percent for right knee shell fragment wound residuals, limitation of motion, is denied. A rating higher than 10 percent for left knee shell fragment wound residuals, limitation of motion, is denied. A separate 10 percent rating for right knee shell fragment wound residuals, muscle injury, is granted. A separate 10 percent rating for left knee shell fragment wound residuals, muscle injury, is granted. A compensable rating for right knee scar is denied. A compensable rating for left knee scar is denied. A rating higher than 10 percent for left cervical spine shell fragment wound degenerative changes is denied. A separate 10 percent rating for left cervical shell fragment wound residuals, muscle injury, is granted. A 40 percent rating bilateral eye disability, to include glaucoma and cataracts, is granted. A rating higher than 50 percent for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's bilateral knee shell fragment wound residuals manifest as arthritis, noncompensable limitation of flexion with pain, severe pain when struck, and retained metallic densities from the original penetrating injuries. 2. The Veteran's bilateral knee scars are not painful or unstable, each affect total areas less than 144 square inches (929 sq. cm.), and do not cause functional impairment. 3. The Veteran's left cervical spine shell fragment wound with degenerative changes manifests as intermittent pain and combined range of motion of the cervical spine no less than 220 degrees. Additionally, he has retained metallic fragments in the muscles of his neck. 4. The Veteran's bilateral eye disabilities manifest as no more than light perception in his right eye, but not anatomic loss of that eye; left eye reduction of visual field to no less than 48 degrees of average concentric contraction; and required continuous medication. He did not have impairment of muscle function, incapacitating episodes, or a compensable loss of visual acuity. 5. The Veteran's PTSD with TBI causes occupational and social impairment with reduced reliability and productivity due to symptoms such as chronic sleep impairment, nightmares, mild memory loss, flattened affect, disturbances in motivation and mood (anxiety and depression), and difficulty in establishing and maintaining effective work and social relationships. 6. The Veteran's service-connected disabilities have not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for right knee shell fragment wound residuals, limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, 4.73, Diagnostic Codes 5003-5260. 2. The criteria for a rating higher than 10 percent for left knee shell fragment wound residuals, limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, 4.73, Diagnostic Codes 5003-5260. 3. The criteria for a separate 10 percent rating for right knee shell fragment wound residuals, muscle injury, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.71a, 4.73, Diagnostic Code 5314. 4. The criteria for a separate 10 percent rating for left knee shell fragment wound residuals, muscle injury, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.71a, 4.73, Diagnostic Code 5314. 5. The criteria for a compensable rating for right knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7802. 6. The criteria for a compensable rating for left knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7802. 7. The criteria for a rating higher than 10 percent for left cervical spine shell fragment wound with degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, Diagnostic Code 5237. 8. The criteria for a separate 10 percent rating for left cervical shell fragment wound residuals, muscle injury, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.73, Diagnostic Code 5323. 9. The criteria for a 40 percent rating, but not rating higher, for bilateral eye disability, to include glaucoma and cataracts, have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Code 6080, 6064. 10. The criteria for a rating higher than 50 percent for PTSD with TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.124a, 4.130, Diagnostic Codes 8045-9411. 11. The criteria for a total disability rating based on individual unemployability due to service-connected disability (TDIU) have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.3, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1966 to May 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March 2013 and June 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The March 2013 rating decision denied the Veteran's increased ratings claims for left cervical spine shell fragment wound with degenerative changes, headaches, right knee shell fragment wound residuals, left knee shell fragment wound residuals, right knee scar, and left knee scar and his attempt to reopen a claim of service connection for low back disability. The Veteran initiated his appeal with an April 2013 notice of disagreement. The RO issued a statement of the case in October 2016 and the Veteran perfected his appeal with a December 2016 VA Form 9. The June 2015 rating decision denied the Veteran's increased ratings claims for right eye cataract, glaucoma, and PTSD and denied his attempt to reopen claims of service connection for residuals of head injury and hepatitis C. The Veteran initiated an appeal of these disabilities and the inferred TDIU claim with a June 2015 notice of disagreement. In a March 2018 rating decision, the RO granted a 50 percent, the maximum available, rating for headaches effective December 7, 2017, granted service connection for a top of head scar, and denied an increased rating for PTSD. The RO then issued a statement of the case in March 2018 on the issues of an increased rating for PTSD with traumatic brain injury (TBI), right eye cataract, and glaucoma; service connection for hepatitis C; and TDIU. The Veteran perfected his appeal with a March 2018 VA Form 9. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in November 2019. A transcript of the hearing is associated with the claims file. In an April 2020 decision, the Board reopened the claims of service connection for hepatitis C and low back disability; granted service connection for a low back disability; denied an increased rating for headaches prior to November 28, 2017; granted an increased rating for headaches from November 28, 2017 to December 6, 2017; remanded the issue of service connection for hepatitis C; remanded the issues of increased ratings for right knee scar, left knee scar, right knee shell fragment wound residuals, left knee shell fragment wound residuals, left cervical spine shell fragment wound residuals, glaucoma, right eye cataract, and PTSD with TBI; and remanded TDIU. In a January 2021 rating decision during the pendency of this appeal, the Veteran was awarded service connection for hepatitis C and scar of the right side of the lower neck. This is a full grant of the benefit sought with regard to the issue of service connection for hepatitis C and, therefore, it is no longer before the Board. Regarding the evaluation assigned for hepatitis C and scar of the right side of the lower neck, the Veteran filed a January 2021 VA Form 10182, noting that he desired direct review by a VLJ under the Appeals Modernization Act (AMA) system. As such, these matters will not be addressed herein, but will be separately addressed under the AMA system. As explained below, a single rating for the Veteran's bilateral eye disability is more favorable to the Veteran than the separate ratings on appeal. As such, these claims have been combined into a single issue as reflected on the title page. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 1. Increased ratings for bilateral knee shell fragment wound residuals and scars The Veteran was originally service connected for bilateral knee conditions and bilateral knee scars in a June 2003 rating decision. At that time, these disabilities were all rated noncompensable (0 percent) effective March 20, 2002. In a December 2009 rating decision, the Veteran's ratings for residuals of shell fragment wound, left knee, and right knee disability were increased to 10 percent each under DC 5260-5010; both effective March 18, 2002. The Veteran's current increased ratings claim was received February 10, 2012. The March 2013 rating decision on appeal denied the Veteran's claim for increased ratings, including separate compensable ratings for injury to muscle group XIV. The Veteran's residual shell fragment wounds of the bilateral knees are each rated under hyphenated diagnostic code 5314-5260. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code (DC) 5314, provides rating criteria for injuries to Muscle Group XIV. 38 C.F.R. § 4.73. Under DC 5314, a 40 percent rating is warranted for a severe muscle injury; a 30 percent rating is warranted for a moderately severe muscle injury; a 10 percent rating is warranted for a moderate muscle injury; and a noncompensable (0 percent) rating is warranted for a slight muscle injury. Id. Under Diagnostic Codes 5301 to 5323, muscle injury disabilities are rated as slight, moderate, moderately severe, or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56 (d). The cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, and impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56 (c). A "slight" disability is characterized by an injury of a simple wound of muscle without debridement or infection. History and complaint are a superficial wound with brief treatment and return to duty, healing with good functional results, and no cardinal signs or symptoms of muscle disability. Objective findings are minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56 (d)(1). A "moderate" disability is characterized by an injury of a through and through or deep penetrating wound of a short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, with residuals of debridement, or prolonged infection. History and complaint are treatment for the wound and consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings are entrance and (if present) exit scars that are small or linear, indicating a short track of missile through muscle tissue, some loss of deep fascia or muscle substance or impairment of muscle tonus, and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d)(2). A "moderately severe" disability is characterized by an injury of a through and through or deep penetrating wound of a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. History and complaint are a service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. Objective findings are entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3). A "severe" muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. History and complaint are the service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed, and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell or harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) x-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(4). Under Diagnostic Code 5260 for limitation of flexion of the leg, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. VA amended the criteria for rating Musculoskeletal System disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Nevertheless, the criteria for DC 5260 was not changed. The Veteran's bilateral knee scars are rated under Diagnostic Code 7802. The rating criteria for evaluating certain types of scars and skin disabilities were amended effective August 13, 2018. 83 Fed. Reg. 32,592 (July 13, 2018) (eff. Aug. 13, 2018). However, the revisions made to Diagnostic Code 7802 did not affect the rating criteria or how those criteria are applied. Compare 38 C.F.R. § 4.118, Diagnostic Code 7802 (2017) with 38 C.F.R. § 4.118, Diagnostic Code 7802 (2019). Instead, the amendment simply clarified the wording of the explanatory notes accompanying Diagnostic Code 7802. Since the changes resulting from the amendment were not functional, in nature, the Board will not address the pre- and post-amendment versions of the criteria herein. As the post-amendment language contained in the notes accompanying Diagnostic Code 7802 is clearer, and as there is no difference in the practical application of the pre-amendment and post-amendment wording, the Board will utilize the post-amendment language. Under Diagnostic Code 7802, a 10 percent rating is warranted for scars not of the head face or neck, that are not associated with underlying soft tissue damage and affect an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802. Where a Diagnostic Code does not provide a noncompensable rating, a noncompensable rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Service treatment records from the time of the original July 1968 injury show that the Veteran's wounds to the knees, forehead, and right shoulder were debrided. He had progressive wound healing without any complications. He was discharged to duty approximately three weeks later. The November 2012 VA knee and lower leg conditions disability benefits questionnaire (DBQ) notes diagnoses of bilateral knee shell fragment wounds with chronic residual pain bilaterally and left knee arthritis. He had pain after climbing nine steps, but not with normal walking. Bumping either knee resulted in persistent sharp pain for an hour. His knees did not lock, but tended to give out unpredictably, causing stumbling without a fall. His range of motion was preserved and he could squat, but not kneel. He did not use a brace and was not treated with injections. He did not report flare-ups. Range of motion testing found right knee flexion to 105 degrees, left knee flexion to 120 degrees, and full range of extension bilaterally with objective evidence of pain at the ends of these ranges. He was able to perform repetitive use testing without additional loss of range of motion. He did not have functional loss or functional impairment of either knee or lower leg. The Veteran did not have tenderness or pain to palpation for joint line or soft tissues of either knee. He had full muscle strength in bilateral flexion and extension. Stability testing was normal bilaterally. He did not have current evidence or a history of recurrent patellar subluxation or dislocation. He did not have a history of or currently have "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. He had not had any meniscal conditions or surgical procedures for a meniscal condition. He had not had a total knee joint replacement, arthroscopic surgery, or any other knee surgery. He had associated scars, but these were not painful and/or unstable or affecting a total area greater than 39 square centimeters (6 square inches). He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his bilateral knee disabilities. He did not use an assistive device as a normal mode of locomotion. The Veteran's bilateral knee disabilities did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed left knee arthritis. There was no x-ray evidence of patellar subluxation. Metallic densities were found in both knees. He had mild bilateral crepitus. These bilateral knee disabilities did not impact the Veteran's ability to work. The November 2012 VA scars DBQ notes multiple small shell fragment scars around the bilateral kneecaps. These scars were not painful or unstable. They were not caused by burns. On his right knee, the Veteran had three superficial nonlinear scars measuring 2 cm x 1 cm (supermedial to patella), 1.5 cm x 1.5 cm (overlying patella), and 1 cm x 1 cm (inferolateral to patella) for a total affected area of 3 square centimeters. On his left knee, he had four nonlinear scars measuring 2 cm x 4 cm (supermedial to patella), 11 cm x 1 cm (overlying upper patella), 1 cm x 1 cm (overlying mid patella), and 1.5 cm x 1.5 cm (overlying inferior patella) for a total affected area of 8 square centimeters. These scars did not result in limitation of motion. These scars were all freely moveable, nontender, and not raised or depressed. They were all slightly hyperpigmented. These scars did not impact the Veteran's ability to work. A January 2013 VA muscle injuries DBQ also addressed his shell fragment wounds of the bilateral knees, noting a history of penetrating muscle injury. The examiner described the Veteran's injuries as affected Muscle Group XIV, affecting the extension of the bilateral knees. The Veteran did not have a history of rupture of the diaphragm with herniation or an extensive muscle hernia of any muscle. He had associated minimal scars. He did not have any known fascial defects or evidence of fascial defects associated with his muscle injuries. His muscle injuries did not affect muscle substance or function. He did not have any of the cardinal signs or symptoms of muscle disability. He had full muscle strength in bilateral knee extension and did not have muscle atrophy. He did not use an assistive device as a normal mode of locomotion. The Veteran's muscle conditions did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. He had no other pertinent physical findings, complications, conditions, signs, or symptoms. There was no x-ray evidence of retained metallic shell fragments. His wounds were superficial and not tender or adherent. There was no muscle, nerve, or artery involvement. These disabilities did not impact the Veteran's ability to work. At the time of his September 2016 knee and lower leg conditions DBQ, the Veteran reported flare-ups of pain. He did not report having any functional loss or functional impairment of the knees. Range of motion testing found right knee flexion to 140 degrees, left knee flexion to 120 degrees, and full range of extension bilaterally with pain noted in bilateral flexion that did not result in or cause functional loss. There was no evidence of pain with weightbearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or loss of range of motion. He was not examined immediately after repetitive use over time or during a flare-up and the examiner found that this examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. There were no additional contributing factors of disability in either knee. He had full muscle strength in bilateral knee flexion and extension without reduction in muscle strength. No ankylosis was found in either knee. The Veteran did not have a history of recurrent subluxation or lateral instability in either knee. He did not have a history of recurrent effusion. Stability testing was normal bilaterally and no instability was found. He did not have a history of or currently have "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. He did not have a history of or currently have any meniscal condition. He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his bilateral knee disabilities. He had associated scars, but these were not painful and/or unstable or affecting a total area greater than 39 square centimeters (6 square inches). He did not use an assistive device as a normal mode of locomotion. The Veteran's bilateral knee disabilities did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies did not document arthritis, but did find retained fragments bilaterally. These bilateral knee disabilities did not impact the Veteran's ability to work. The September 2016 scars DBQ notes shell fragment wound scars to the bilateral knees. These scars were not painful or unstable. They were not caused by burns. On his right knee, the Veteran had two linear scars measuring 5 cm (on patella) and 3 cm (proximal medial to patella) and two superficial nonlinear scars measuring 1 cm x 1 cm (lateral to patella) and 2 cm x 1 cm (proximal to patella). On his left knee, he had two linear scars measuring 7 cm (on patella) and 3 cm (proximal to patella). These scars did not result in limitation of motion. These scars did not impact the Veteran's ability to work. At the time of his November 2018 knee and lower leg conditions DBQ, the Veteran reported chronic and persistent pain localized to the anterior compartment of both knees that had increased in the prior two years. His pain triggers were repeat trauma to the front of the knees or bumping the front of the knees against objects. The Veteran took ibuprofen for his knee pain. He had had no physical therapy, knee joint aspiration, knee joint injection, or surgical treatment for his knees since the time of his previous compensation and pension knee examination in September 2016. He lived alone in a house and had driven himself to the examination. He retired as a truck driver for the city of Chicago in 2010. He had also driven a taxicab from 1996 until 2012. Range of motion testing found flexion to 125 degrees and full range of extension bilaterally with pain noted in bilateral flexion that did not result in or cause functional loss. There was no evidence of pain with weightbearing, no evidence of pain with non-weightbearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or loss of range of motion. He was not examined immediately after repetitive use over time or during a flare-up and the examiner found that this examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time and during a flare-up. Pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability after repetitive use over time or during a flare-up. There were no additional contributing factors of disability in either knee. He had full muscle strength in bilateral knee flexion and extension without reduction in muscle strength. No ankylosis was found in either knee. The Veteran did not have a history of recurrent subluxation or lateral instability in either knee. He did not have a history of recurrent effusion. Stability testing was normal bilaterally and no instability was found. He did not have a history of or currently have "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. He did not have a history of or currently have any meniscal condition. He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his bilateral knee disabilities. He had associated scars, but these were not painful and/or unstable or affecting a total area greater than 39 square centimeters (6 square inches). He did not use an assistive device as a normal mode of locomotion. The Veteran's bilateral knee disabilities did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed bilateral arthritis and metallic densities in both knees. These bilateral knee disabilities could impact the Veteran's ability to work in that he could have problems in an occupational setting performing jobs that require physical work such as squatting to lift heavy loads. He could tolerate other forms of work that fall in the light duty ranges of physical demand. This examiner characterized the Veteran's bilateral knee disabilities as mild. The November 2018 scars DBQ notes the Veteran's history of multiple shell fragment wounds to his bilateral knees and lower legs in service. These scars were not due to burns. On his right knee, the Veteran had three well-healed, superficial, nonlinear scars on the anterior compartment of knee, each measuring 2 cm x 2 cm. On his left knee, he had two well-healed, superficial, nonlinear scars on the anterior compartment of knee, each measuring 2 cm x 2 cm. These scars were not painful or unstable and did not result in functional loss of the knees. He also had multiple, well-healed, residual hypopigmented areas of scarring noted throughout the bilateral shin area. These areas were consistent with healed superficial abrasion scars involving the right shin. These hypopigmented areas were too numerous to count. They were not painful or unstable. The scars did not result in any functional loss or limitation. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms associated with these scars. These scars did not impact the Veteran's ability to work. At his November 2019 hearing, the Veteran testified that his knee disabilities prevented kneeling and weight bearing. If he accidentally bumped either knee it caused severe pain for the rest of the day. He treated his knee pain with ibuprofen. He also reported worsening instability in the right knee. At the time of his October 2020 knee and lower legs conditions DBQ, the Veteran denied flare-ups of the knees or lower legs. He did not report any functional loss or impairment of the knees or lower legs. The Veteran had full range of motion in the bilateral knees with no pain noted on examination. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or loss of range of motion. He was not examined immediately after repetitive use over time and the examiner found that this examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability after repetitive use over time. There were no additional contributing factors of disability in either knee. He had full muscle strength in bilateral knee flexion and extension and no muscle atrophy. No ankylosis was found in either knee. The Veteran did not have a history of recurrent subluxation or lateral instability in either knee. He did not have a history of recurrent effusion. Stability testing was normal bilaterally and no instability was found. He did not have a history of or currently have "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. He did not have a history of or currently have any meniscal condition. He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his bilateral knee disabilities. He did not use an assistive device as a normal mode of locomotion. The Veteran's bilateral knee disabilities did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. These bilateral knee disabilities did not impact his ability to work. The October 2020 muscle injuries DBQ notes that the Veteran had some superficial scarring to both knees and shins, but no muscle injury or loss of function to either knee. He had minimal scars. He had no cardinal signs or symptoms of muscle disability. He had full muscle strength throughout and no muscle atrophy. He did not use an assistive device as a normal mode of locomotion. The Veteran's muscle conditions did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms. The Veteran's muscle injuries did not impact his ability to work. The October 2020 scars DBQ notes the Veteran's history of scarring of the bilateral knees. He had multiple, well-healed, residual hypopigmented areas throughout his bilateral shins. These scars were not painful, unstable, or due to burns. On his right knee, the Veteran had three scars each measuring 2 cm x 2 cm. On his left knee, he had two scars each measuring 2 cm x 2 cm. There was no underlying tissue damage. The scars did not result in any functional loss or limitation. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms associated with these scars. These scars did not impact the Veteran's ability to work. This examiner noted that the Veteran had full range of motion of his bilateral knees despite scattered scars and residual bullet fragments. These scars were not tender to palpation, had no effect on his range of motion, and did not interfere with walking. No functional deficits were noted. 1. Shell fragment wound residuals of bilateral knees The Veteran's shell fragment wound residuals of the bilateral knees are currently rated 10 percent based on limitation of motion. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for either right knee shell fragment wound residuals or left knee shell fragment wound residuals based on limitation of motion. The Veteran's related symptoms include radiologic evidence of bilateral knee arthritis, range of motion of the bilateral knees was limited to no less than 105 degrees flexion in the right and 120 flexion in the left, full range of extension bilaterally, full muscle strength, and no ankylosis or atrophy. He did not use an assistive device as a normal mode of locomotion. There was no objective evidence of pain with weightbearing or non-weightbearing and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Despite his reports of instability, objective stability testing repeated found both knees stable. Functionally, the Veteran reported limitations on kneeling, prolonged stairclimbing, and weightbearing. If he bumped either knee, the resulting severe pain lasted for the rest of the day. Additionally, he reported that these bilateral knee disabilities would render him unsafe to operate a commercial vehicle. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by these statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. As such, a rating higher than 10 percent for either knee is not warranted based on painful limitation of flexion. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Here, as noted, there is no evidence of recurrent subluxation and repeated stability testing consistently found both knees stable, so separate ratings under DC 5257 are not warranted. Additionally, both knees consistently had full range of extension, so separate ratings under DC 5261 are not warranted. No dislocation or removal of the meniscus was shown in either knee, so neither DC 5258 nor DC 5259 apply. Likewise, there is no evidence of genu recurvatum, so a separate rating under DC 5263 is not warranted for either knee. Finally, there is no evidence of ankylosis (or the functional equivalent of ankylosis) or impairment of the tibia and fibula of either knee, so DC 5256 and DC 5262 do not apply. As none of these DCs apply, discussion of the corresponding revisions to their rating criteria as of February 7, 2021 is not necessary. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for shell fragment wound residuals, limitation of motion, for either knee. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board has also considered whether separate ratings are warranted for either knee under DC 5314. The Veteran has a history of penetrating muscle injury. Objective findings included minimal scars and no evidence of fascial defect, atrophy, or impaired tonus. There was radiologic evidence of retained metallic densities. This is consistent with the criteria for moderate muscle injuries under DC 5314, which warrants separate 10 percent ratings. See 38 C.F.R. § 4.73. A higher rating for either knee under the diagnostic code would require evidence of at least a moderately severe muscle injury characterized by an injury of a through and through or deep penetrating wound of a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring; prolonged hospitalization for treatment of the wound; consistent complaints of cardinal signs and symptoms of muscle disability; objective findings of entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles; and positive evidence of impairment in strength and endurance testing. None of these symptoms are present nor are there symptoms of similarly severity. As such, the Veteran's shell fragment wound residuals of the bilateral knees are both found to be no more than moderate muscle injuries. Thus, separate 10 percent ratings are assigned for each knee due to muscle injuries. To this extent, his appeal is granted. 2. Scars Based on the above evidence, the preponderance of the evidence is against a finding that a compensable rating is warranted for the scars on either knee. The Veteran's current noncompensable ratings are assigned for superficial, nonlinear scars of the bilateral knees. Based on the measurements contained in the examination reports, the total areas affected on the Veteran's knees by these scars does not more nearly approximate the 929 cm. sq. area contemplated by a compensable rating for superficial non-linear scars. As such, a compensable rating is not warranted in this case. 38 C.F.R. §§ 4.3, 4.7, 4.31, 4.118, Diagnostic Code 7802. No additional higher or alternative ratings under different Diagnostic Codes can be applied. There is no evidence that the noted scars are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Likewise, each examiner noted that the scars are not painful or unstable, and that there is no evidence of other disabling effects associated with the bilateral knee scars. 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805. All potentially applicable Diagnostic Codes have been considered. See Schafrath, 1 Vet. App. at 593. The preponderance of the evidence is against a compensable rating for the Veteran's service-connected lower extremity scars. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claims for compensable ratings for scars of the bilateral knees are denied. 2. A rating higher than 10 percent for left cervical spine shell fragment wound degenerative changes The Veteran was granted service connection for left cervical spine shell fragment wound in the July 2012 rating decision. At that time, this disability was rated 10 percent effective March 20, 2002. The Veteran's February 2012 claim for an increased rating for a back disability was subsequently expanded to include a claim for an increased rating for his cervical spine disability and was addressed in the March 2013 rating decision currently on appeal. The Veteran's left cervical spine shell fragment wound degenerative changes (cervical spine disability) is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Additionally, DC 5323 provides rating criteria for injuries to Muscle Group XXIII, the muscles of the side and back of the neck. Under this diagnostic code, a slight muscle injury is assigned a 0 percent rating; a moderate muscular disability is assigned a 10 percent rating; a moderately severe muscular disability is assigned a 20 percent rating; and severe muscle disability is assigned the schedular maximum 30 percent rating. 38 C.F.R. §§ 4.55, 4.56, 4.73, Diagnostic Code 5323. Again, "slight," "moderate," "moderately severe," and "severe" are defined in 38 C.F.R. § 4.56, as described above in the bilateral knee discussion. VA treatment records for the appeal period show complaints of neck pain without radiation, tenderness, or spasm. A cervical pillow was ordered in September 2018. The May 2003 VA joints exam notes that the Veteran was unemployed but this was not secondary to any service-connected disability or injury. He complained of occasional neck pain, but no numbness or weakness of the upper extremities and no difficulty with ambulation. He had a history of shrapnel injuries to the right shoulder, and head, but no pain associated with his shrapnel wounds or retained fragments themselves. His cervical spine range of motion was normal without limitation. He had flexion of chin-to-chest, extension to 45 degrees, bilateral lateral bending to 35 degrees, and bilateral lateral rotation to 35 degrees. The December 2009 joints exam noted that the Veteran reported intermittent pain and stiffness in the base of his neck approximately every six months. This pain was localized to the right lateral aspect of the neck, posteriorly. It was random and unrelated to activity. He treated this pain with over-the-counter pain medication. Physical examination found no tenderness of muscle spasm. He had full range of flexion and extension. Lateral flexion was limited to 30 degrees bilaterally and lateral rotation was limited to 50 degrees bilaterally. There was no evidence of shell fragment wound to the cervical spine. X-rays showed degenerative disc disease and metallic densities in the soft tissues of the posterior neck. He had no scars or wounds involving his left cervical area. The November 2012 neck conditions DBQ notes the Veteran's complaints of occasional flare-ups of neck pain. His range of motion of the cervical spine was 45 degrees of forward flexion, 15 degrees of extension, 20 degrees of bilateral lateral flexion, and 60 degrees of bilateral lateral rotation. There was no objective evidence of painful motion. He was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or range of motion after three repetitions. The Veteran did not have localized tenderness, guarding, or muscle spasm of the cervical spine. He had full muscle strength in the bilateral upper extremities. He did not have muscle atrophy. His reflexes were normal throughout the bilateral upper extremities. His sensory exam results were normal. He did not have radicular pain or any other signs or symptoms due to radiculopathy. The Veteran did not have any other neurologic abnormalities related to a cervical spine condition. He did not have intervertebral disc syndrome (IVDS) of the cervical spine. He did not use an assistive device. The Veteran's cervical spine disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. He had an associated scar, but it was not painful or unstable and did not affect an area greater than 39 square cm (6 square inches). Imaging studies were not performed. This disability did not impact the Veteran's ability to work. At his November 2019 hearing, the Veteran testified that his cervical spine disability was characterized by pain and variable range of motion. The October 2020 neck conditions DBQ notes that the Veteran did not report flare-ups of the cervical spine or any functional loss or functional impairment. Range of motion testing was all normal with no pain noted on examination. There was no evidence of pain on passive range of motion or non-weightbearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination significantly did not limit functional ability with repeated use over a period of time. The Veteran did not have localized tenderness, guarding, or muscle spasm of the cervical spine. There were no additional factors contributing to disability. He had full muscle strength in the bilateral upper extremities. He did not have muscle atrophy. His reflexes were normal throughout the bilateral upper extremities. His sensory exam results were normal. He did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine. The Veteran did not have any other neurologic abnormalities related to a cervical spine condition. He did not have intervertebral disc syndrome (IVDS) of the cervical spine. He did not use an assistive device. The Veteran's cervical spine disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. He had an associated 1.5 cm x 1 cm scar on the right side of the lower neck, but it was not painful or unstable. He did not have any other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies were not performed. This disability did not impact the Veteran's ability to work. The October 2020 muscle injuries DBQ notes that the Veteran had some superficial scarring to the back of his neck, but no muscle injury or loss of function to his neck. He had minimal scars. He had no cardinal signs or symptoms of muscle disability. He had full muscle strength throughout and no muscle atrophy. He did not use an assistive device as a normal mode of locomotion. The Veteran's muscle conditions did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. He did not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms. The Veteran's muscle injuries did not impact his ability to work. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left cervical spine shell fragment wound with degenerative changes. The Veteran's cervical spine disability manifests as intermittent pain and combined range of motion of the cervical spine no less than 220 degrees. This is consistent with the current 10 percent rating. See 38 C.F.R. § 4.71a, 5237. The record does not show and the Veteran does not allege symptoms that would not result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Finally, the Board has considered whether the Veteran's cervical spine disability warrants a separate rating based on the criteria for muscle injuries. Despite the October 2020 examiner's assertion that the Veteran had no muscle injury or loss of function to his neck, the record clearly shows evidence of retained metallic fragments. Under 38 C.F.R. § 4.56 (d)(1), a slight muscle injury has no metallic fragments retained in the muscle tissue; therefore, his cervical spine muscle injury must be at least moderate. A higher rating under the diagnostic code would require evidence of at least a moderately severe muscle injury characterized by an injury of a through and through or deep penetrating wound of a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring; prolonged hospitalization for treatment of the wound; consistent complaints of cardinal signs and symptoms of muscle disability; objective findings of entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles; and positive evidence of impairment in strength and endurance testing. None of these symptoms are present nor are there symptoms of similarly severity. As such, the Veteran's left cervical spine shell fragment wound residuals, muscle injury, is found to be no more than a moderate muscle injury. Thus, a separate 10 percent rating is assigned for muscle injury and to this extent, his appeal is granted. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for cervical spine with degenerative changes disability. The evidence supports the assignment of a separate 10 percent rating, but no higher, for the cervical spine, muscle injury, disability. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. A rating higher for bilateral eye disability, to include glaucoma and cataracts The Veteran was granted service connection for right eye cataract and glaucoma in a July 2012 rating decision. At that time, his cataract was rated 30 percent and his glaucoma was rated 10 percent both effective October 28, 2005. Additionally, he was awarded special monthly compensation for loss of use of one eye also effective October 28, 2005. The Veteran's claim for increased ratings was received December 10, 2014. The Veteran's glaucoma is rated under DC 6013 and his right eye cataract is rated under DC 6027-6065. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15,316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, DC 6013 instructed the rater to evaluate open-angle glaucoma based on visual impairment with a minimum 10 percent evaluation if continuous medication was required. 38 C.F.R. § 4.79 (2014). Under the former criteria, DC 6027 instructed that preoperative cataracts were to be rated based on impairment of vision and postoperative cataracts were to be rating on impairment of vision if a replacement lens was present and based on aphakia if a replacement lens was not present. 38 C.F.R. § 4.79 (2014). DC 6029 provided a 30 percent minimum rating for aphakia or dislocation of the crystalline lens and instructed that the evaluation should be based on visual impairment with a one-step elevation. Id. Under the revised DC 6013 for open-angle glaucoma instructs the rater the evaluate under the General Rating Formula for Disease of the Eye, with a minimum 10 percent rating if continuous medication is required. Likewise, revised DC 6027 instructs the rater to evaluate preoperative cataract or postoperative cataract with a replacement len (pseudophakia) under the General Rating Formula for Diseases of the Eye. 38C.F.R. §4.79. Postoperative cataract without a replacement len (aphakia) is evaluated under DC 6029 based on visual impairment with the resulting level of impairment elevated up one step and a minimum rating of 30 percent for unilateral or bilateral aphakia. See id. Similarly, under the current diagnostic code (DC 6040), diabetic retinopathy is rated under the General Rating Formula for Diseases of the Eye. See id. Under the revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The criteria for visual impairment, including impairments of visual acuity, visual fields, and/or muscle function, have remained unchanged. Impaired visual acuity is rated under diagnostic codes 6061-6066 based on the best corrected distance vision. 38 C.F.R. §§ 4.76, 4.79. Impairment of visual fields are rated under DC 6080-6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Impaired muscle function is rated under DC 6090-6091 with an evaluation for diplopia being assigned to only one eye. 38 C.F.R. §§ 4.78, 4.79. VA treatment records from the appeal period show no vision in the right eye. The Veteran's left eye visual acuity was consistently correctable to 20/40 or better and his visual field was described as full or essentially full except for a possible inferior nasal defect noted in September 2016. The September 26, 2014, visual field perimeter chart showed loss of visual field as described below: Meridian Normal Left Eye Temporally 85 70 Down temporally 85 65 Down 65 63 Down nasally 50 50 Nasally 60 53 Up nasally 55 55 Up 45 45 Up temporally 55 55 Total: 500 456 Average Concentric Contraction 62.5 57 The June 20, 2014, visual field perimeter chart showed loss of visual field as described below: Meridian Normal Left Eye Temporally 85 70 Down temporally 85 70 Down 65 65 Down nasally 50 50 Nasally 60 60 Up nasally 55 45 Up 45 45 Up temporally 55 53 Total: 500 458 Average Concentric Contraction 62.5 57.25 The April 2015 eye conditions DBQ diagnoses glaucoma and cataract. His distance and near corrected visual acuity in the left eye were 20/40 or better. An afferent pupillary defect was present in the right eye. His vision in right eye was limited to no more than light perception only. With his right eye, he was not able to recognize test letters at one foot or closer or to perceive objects, hand movements, or count fingers at three feet. He did not have a corneal irregularity that resulted in severe irregular astigmatism. He did not have diplopia. He had a scarred bleb on the right conjunctiva/sclera, dilated right iris, and bilateral cataracts. His right optic disc was .95/.95. The Veteran had visual field loss, specifically there was no vision in his right eye. He did not have a scotoma. He did not have statutory blindness based on his impairment of bilateral visual acuity or visual field loss. The Veteran had bilateral preoperative cataracts. There was no aphakia or dislocation of the crystalline lens. His open-angle glaucoma of the right eye required continuous medication. His visual impairment was attributed to his glaucoma. There was no scarring or disfigurement attributable to any eye condition. In the prior twelve months, the Veteran had not had any incapacitating episodes attributable to any eye condition. His eye disabilities affected his ability to work in that he had monocular limitations and restrictions. In his July 2015 notice of disagreement, the Veteran argued that he was entitled to a higher rating for his eye disabilities because he was blind in his right eye and required continuous medication (eye drops). The May 18, 2017, visual field perimeter chart showed loss of visual field as described below: Meridian Normal Left Eye Temporally 85 70 Down temporally 85 77 Down 65 62 Down nasally 50 50 Nasally 60 60 Up nasally 55 55 Up 45 45 Up temporally 55 55 Total: 500 474 Average Concentric Contraction 62.5 59.25 At his November 2019 hearing, the Veteran testified that he no longer had vision in his right eye and therefore could no longer work as a truck driver. Thus, he was no longer employed. The October 2020 eye conditions DBQ notes bilateral glaucoma and bilateral cataracts. He had undergone glaucoma surgery on his left eye in 2001. His visual acuity in the right eye was 5/200 or worse in both distance and near with or without correction. In his left eye, the Veteran's uncorrected distance vision was 20/40 and his uncorrected near vision was 20/100, both correctable to 20/20 or better. His pupils were not equal, round, and reactive to light. He had an afferent pupillary defect in the right eye. His vision in right eye was limited to no more than light perception only. With his right eye, he was not able to recognize test letters at one foot or closer or to perceive objects, hand movements, or count fingers at three feet. He did not have statutory blindness based on his impairment of bilateral visual acuity. He did not have a corneal irregularity that resulted in severe irregular astigmatism. He did not have diplopia. An external eye exam revealed bilateral cataracts and a flat bleb on his right conjunctiva/sclera. Internally, his right eye had a cup-to-disc ration of 1. He did not have a documented visual field defect. Nevertheless, the accompanying visual field perimeter chart showed loss of visual field as described below: Meridian Normal Left Eye Temporally 85 70 Down temporally 85 58 Down 65 40 Down nasally 50 40 Nasally 60 40 Up nasally 55 52 Up 45 35 Up temporally 55 55 Total: 500 390 Average Concentric Contraction 62.5 48.75 The Veteran had bilateral open-angle glaucoma that required continuous medication. He also had bilateral preoperative cataracts. There was no pseudophakia, aphakia, or dislocation of the crystalline lens. His visual impairment was attributed to his glaucoma. There was no scarring or disfigurement attributable to any eye condition. In the prior twelve months, the Veteran had not had any incapacitating episodes attributable to any eye condition. His eye disabilities did not affect his ability to work. The Veteran's current eye ratings (30 percent for right eye cataract and 10 percent for glaucoma) combine to 37 percent. Based on the above, a slight increase to a single 40 percent rating is warranted. The Veteran has no more than light perception in his right eye, but not anatomic loss of that eye. His left eye his field of vision was reduced to no less than 48 degrees of average concentric contraction, which equates to 20/50 visual acuity. The Veteran's left eye visual acuity was correctable to no worse than 20/40. He did not have impairment of muscle function or incapacitating episodes. His glaucoma required continuous medication. When the worse eye has no more than light perception and the better eye is 20/50, a 40 percent rating is warranted. See 38 C.F.R. § 4.78, DC 6064. As he has a compensable visual impairment attributable to glaucoma, the minimum 10 percent rating under DC 6013 is satisfied. Thus, the Veteran's bilateral eye disabilities more nearly approximate the criteria for a single 40 percent rating, which is a slight increase, and to that extent, his appeal is granted. 4. A rating higher than 50 percent for PTSD with TBI The Veteran was originally service connected for PTSD in a May 2007 decision review officer (DRO) decision. At that time, this disability was rated 30 percent effective September 16, 2004. In a February 2010 rating decision, this was increased to 50 percent effective January 15, 2008. The Veteran's current claim for increased ratings was received December 10, 2014. This disability is currently rated under hyphenated diagnostic code 8045-9411. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Residuals of traumatic brain injury (TBI) are rated under Diagnostic Code (DC) 8045. 38 C.F.R. § 4.124a. Under this diagnostic code, there are three main areas of dysfunction that may result from a traumatic brain injury (TBI) and have profound effects on functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified (hereinafter "Not Otherwise Classified Table"). Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the Not Otherwise Classified Table. However, any residual with a distinct diagnosis, such as migraine headache or Meniere's disease, that may be evaluated under another diagnostic code must be separately evaluated, rather than under this Table; even if that diagnosis is based on subjective symptoms. See 38 C.F.R. § 4.124a. VA is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the Not Otherwise Classified Table. VA is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed in 38 C.F.R. § 4.124a, DC 8045, that are reported on an examination, VA is to evaluate under the most appropriate diagnostic code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the Not Otherwise Classified Table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The Not Otherwise Classified Table contains 10 important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." Not every facet has every level of severity, however. The consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. A 100 percent evaluation is assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, a 70 percent evaluation is assigned if 3 is the highest level of evaluation for any facet. There may be an overlap of manifestations of conditions evaluated under the Not Otherwise Classified Table with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. 38 C.F.R. § 4.124a, DC 8045 Note (1). In such cases, it is improper to assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, then a single evaluation is to be assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, a separate evaluation should be assigned for each condition. Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. 38 C.F.R. § 4.124a, DC 8045 Note (2). "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. 38 C.F.R. § 4.124a, DC 8045 Note (3). These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. The terms "mild," "moderate," and "severe" traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. 38 C.F.R. § 4.124a, DC 8045 Note (4). This classification does not affect the rating assigned under DC 8045. DC 9411 provides rating criteria for PTSD under the General Formula for Mental Disorders (General Formula). Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. VA treatment records from the appeals period show that the Veteran underwent individual and group therapy in 2014 and 2015. During this period, he was guarded and had a blunted affect. He described his mood in vaguely positive terms like "pretty good," "okay," and "not depressed lately." He was appropriately dressed and groomed during all interactions. He described some periods of decreased motivation. The Veteran had nightmares, sleep difficulties, and mild memory loss, such as misplacing his keys or getting lost in a familiar place. He also endorsed some irritability. The Veteran consistently denied suicidal or homicidal ideation and audio or visual hallucinations. He was retired and lived alone. He reported having contact with his children and grandchildren. He reported some difficulties in his relationships, particularly with his extended family and his neighbors. In response to a question about his PTSD group therapy, the Veteran stated that he liked being part of a group. He reported some isolation, but on at least one occasion, he went to a play by himself and enjoyed it. Shortly before the pandemic, he expressed an interest in returning to treatment, but the record does not show that he has yet done so. The March 2015 PTSD DBQ notes PTSD symptoms including distressing dreams, avoidance of or efforts to avoid external reminders that arouse memories, thoughts, or feelings associated with events, diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior, sleep, social withdrawal, agitation, and interacting with others in an abrasive or brusque manner. This examiner found occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication. The Veteran was no longer with his common-law wife and mother of three of his children. He also had a daughter from another relationship. Since service, he held various jobs with intermittent periods of unemployment. These jobs have included construction worker, gas station service worker, laborer for a tire company, truck driver, and taxicab driver. He was in the process of being credentialed as a volunteer at the VAMC. Prior to service, the Veteran had dropped out of high school as a sophomore and worked as a custodian in a hospital and an order filler. After service, he obtained his GED. Now, his education included some college credits. The examiner noted symptoms of depressed mood, anxiety, and chronic sleep impairment. A mental status examination found the Veteran alert and oriented in all spheres. He was dressed casually and appropriately for the weather. His grooming and eye contact were good. His speech was logical and goal directed. He had no abnormal motor behavior. He reported feeling less agitated and irritable over the prior few days. His affect was appropriate to the topic of conversation. There was no evidence of a psychotic process or core. He did not report any suicidal or homicidal ideation or intent. No significant cognitive or memory deficits were noted. His intelligence fell in the average range. He had some understanding of the emotional, social, and psychological factors that contributed to his personality development. His judgment was unimpaired. In his July 2015 notice of disagreement, the Veteran argued that he was entitled to a higher rating for his PTSD because it caused social and occupational impairment due to chronic sleep impairment, anxiety, and depressed mood. A December 2017 traumatic brain injury (TBI) DBQ notes diagnoses of traumatic brain injury and posttraumatic headaches in 1968 related to being struck on the head by shrapnel from a rocket. He did not lose consciousness. His wounds were treated, but he did not have treatment for TBI. Alternately, he reported striking his head during a motor vehicle accident while service in Vietnam. There was objective evidence of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. Specifically, the Veteran reported difficulty remembering tasks beginning two or three years earlier. He denied difficulty with attention and concentration. His judgment was normal. His social interaction was routinely appropriate. He was always oriented to person, time, place, and situation. His motor activity was normal. His visual spatial orientation was normal. He had subjective symptoms that did not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. These included headaches and poor sleep, but he denied sensitivity to light or sound. He had neurobehavioral effects that do not interfere with workplace interaction or social interaction, including lack of motivation and moodiness, which the examiner found to be more likely related to his PTSD. The Veteran denied irritability, impulsivity, and unpredictability. He was able to communicate by spoken and written language and to comprehend spoken and written language. His consciousness was normal. He had a scar on the top of his head measuring 2 cm x 2 cm. It was not painful or unstable. He did not have any other pertinent physical findings, complications, conditions, signs, or symptoms. This disability impacted the Veteran's ability to work due to headaches and memory difficulties. The December 2017 PTSD DBQ examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran lived alone. He had most frequent contact with his daughter and her children. He also saw his son and his son's daughter occasionally. He mostly spent his days watching television and playing the guitar. Sometimes he would go out by himself to watch a play or see a show. He preferred to be on his own. Since his last examination, the Veteran had volunteered for three to four months at two VA medical centers. He had worked as a transit driver from August 2015 to February 2016. He was currently unemployed and looking for work. The Veteran reported current symptoms of loneliness, fatigue, irritability, boredom, emotionally drained, anxiety over necessary home repairs, feeling guilt over not being able to prevent traumatic events from happening, and nightmares with war themes (once or twice a week). He was not prescribed medication and denied needing medication to address his symptoms. The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss, such as forgetting names, direction, or recent events. The Veteran's mood was euthymic and his affect was congruent. He was polite, fully oriented, well-groomed, and dressed appropriately for the season. He made appropriate eye contact. His speech was fluid and at times difficult to understand due to mumbling, but when asked again he projected his voice and annunciated his words properly. His thought process was fluid and goal directed. He was alert and attentive and he denied current suicidal or homicidal ideation or hallucinations. In a December 2017 opinion, the VA examiner found that it was not possible to separate the level of impairment attributable to the Veteran's PTSD from that attributable to his TBI. At his November 2019 hearing, the Veteran testified that his PTSD was characterized by depression, social avoidance, forgetfulness, occasional panic attacks, and flashbacks. He reported having good relationships with his children and grandchildren. The September 2020 PTSD DBQ examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Since his prior examination, the Veteran reported still living alone. His activities were limited by the pandemic, but he tried to busy himself around the house. He spent more time with friends, but less time with his family. He was studying film photography and learning to develop film and print pictures. Due to the pandemic, he no longer volunteered at VA and no longer attended support groups. He did not take medication for his PTSD. He did not drink or use drugs, but did smoke cigars. The examiner noted symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and impaired impulse control. He was interviewed via telehealth. His grooming was impeccable. His speech was clear, coherent, and relevant. He was fully oriented and there was no evidence of altered thinking ot perception. He attention and concentration were good. He had minor memory lapses, but no major impairments in recall. He denied suicidal and homicidal ideation. His mood was depressed and somewhat irritable. He complained of chronic pain and fatigue. His affect was serious, but appropriate. His judgment, insight, and impulse control were grossly intact. An October 2020 TBI DBQ diagnosed TBI. There was a complaint of mild impairment of memory, attention, concentration, or executive functions, but without objective evidence on testing. Specifically, the Veteran reported misplacing items or being ready to do something and forgetting what he was supposed to do. His judgment was normal. His social interaction was routinely appropriate. He was occasionally disoriented to the day of the week or date, but was always oriented to person, place, and situation. His motor activity was normal. His visual spatial orientation was normal. He had subjective symptoms that did not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. These included weekly headaches and insomnia. He did not have neurobehavioral effects. He was able to communicate by spoken and written language and to comprehend spoken and written language. His consciousness was normal. He did not have any associated scars or other pertinent physical findings, complications, conditions, signs, or symptoms. This disability did not impact his ability to work. Based on the above, the Veteran's PTSD with TBI manifests as chronic sleep impairment, nightmares, mild memory loss, flattened affect, disturbances in motivation and mood (anxiety and depression), and difficulty in establishing and maintaining effective work and social relationships. This is consistent with the current 50 percent rating. He also has a separate rating for associated headaches, which has been appealed under the Appeals Modernization Act and is not currently before the Board. The Veteran has not reported symptoms that would more closely approximate a 70 percent rating. There is no evidence of suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; panic attacks; spatial disorientation; neglect of personal appearance or hygiene; or difficulty in adapting to stressful circumstances. While some depression is shown, it does not rise to the level of near-continuous depression contemplated by the rating criteria and is not shown to have affected his ability to function independently, appropriately, and effectively. While he has previously reported irritability, there is no showing of impaired impulse control. The Veteran reported some social isolation, but has repeatedly shown that he is able to maintain effective relationships with his children and grandchildren; therefore, despite some noted difficulties, the record does not show an inability to establish and maintain effective relationships. As such, the Veteran's symptoms do not more closely approximate the symptoms contemplated by a 70 percent rating. Thus, a rating higher than 50 percent for PTSD with TBI under DC 9411 is not warranted. The Board has also considered whether a higher rating is available under DC 8045 for TBI based on these symptoms. See 38 C.F.R. § 4.124a. The Veteran's associated cognitive impairment is characterized by objective evidence of mild memory loss. Therefore, that facet is level 2. See 38 C.F.R. § 4.124a, Diagnostic Code 8045. He was occasionally disoriented to the day of the week or date, but was always oriented to person, place, and situation, which meets the level 1 criteria for orientation. See id. The Veteran had neurobehavioral effects that do not interfere with workplace interaction or social interaction, including lack of motivation and moodiness, which the December 2017 examiner found to be more likely related to his PTSD. Regardless, these neurobehavioral effects met the criteria for level 0. See id. He had subjective symptoms of headaches and insomnia, which did not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Thus, this facet meets the criteria for level 0. Moreover, his headaches are rated separately and cannot be used to support a higher rating for TBI without violating the rule against pyramiding. See 38 C.F.R. § 4.14. He had no impairments of judgment, social interaction, motor activity, visual spatial orientation, communication, or consciousness; therefore, these facets are all level 0. See 38 C.F.R. § 4.124a, Diagnostic Code 8045. Thus, the highest level of impairment for any facet is level 2, which is the equivalent of a 40 percent rating. See id. This is less than existing 50 percent rating under DC 9411. Therefore, a higher rating for these symptoms under DC 8045 is not available. 5. TDIU Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Here, the Veteran is service connected for PTSD with TBI; headaches; right eye cataract; glaucoma; shell fragment wound right shoulder; shell fragment wound right knee; shell fragment wound left knee; shell fragment wound left cervical spine; lumbar strain with spondylosis; hepatitis C; and scars of the top of the head, right lower neck, right shoulder, and bilateral knees, with a total combined rating of 90 percent since February 10, 2012. Additionally, separate and increased ratings have been granted herein (see above). This is sufficient to meet the schedular criteria for TDIU consideration. Nonetheless, as discussed below, the record does not establish that the Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation during the appeals period. The record also does not show that TDIU is warranted based on a single disability. The Board will now turn to the question of whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The issue is whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The record is unclear as to when the Veteran last worked. Based on the conflicting reports in the record, the Veteran appears to have worked full-time at least until March 2010, when he submitted a Rehabilitation Needs Inventory, he anticipated being reassigned or laid off from his full-time job as a truck driver for the City of Chicago at the end of the month, noting that his position entailed snow removal. At that time, he also stated that he worked full-time as a chauffeur since May 2007 and drove a taxi full-time since 2008. In his August 2011 and December 2011 applications for vocational rehabilitation and his January 2012 Rehabilitation Needs Inventory, the Veteran stated that he was still working as a taxi driver. An August 2017 vocational rehabilitation memorandum states that the Veteran was fired from his part-time job as a driver in August 2012 for cursing out his supervisor. This has not been attributed to his disabilities. At the time of his December 2017 PTSD DBQ, the Veteran stated that he had worked as a transit driver from August 2015 to February 2016. The Veteran has not provided signed and completed Requests for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) for any of his former employers and has not provided sufficient contact information to allow VA to obtain this information itself. Thus, there is insufficient evidence of record to determine whether these positions were marginal, the extent to which his disabilities interfered with employment, and any concessions made during this employment. As detailed above, the Veteran's cervical spine disability, scars, and muscle injuries do not impact his ability to work. His bilateral knee joint disabilities could cause difficulty performing physical work such as squatting to lift heavy loads, but the Veteran could tolerate other light physical work. He also had some occupational impairment due to headaches and memory difficulties. Finally, his visual impairments caused monocular limitations and restrictions. His prior work history includes working as a custodian in a hospital, an order filler, a construction worker, a gas station service worker, a laborer for a tire company, a truck driver, and a taxicab driver. He earned his GED after service and some college courses. He also completed an auto repair technician program in March 2007. The bulk of the Veteran's most recent employment has involved driving and he has repeated stated that his disabilities prevent him from continuing to work as a driver, either due to his bilateral knee disabilities making his operation a commercial vehicle unsafe or due to his vision loss. Nevertheless, despite his extremely limited and decreasing vision in his right eye, the Veteran still reported having a valid commercial driver's license in a February 2012 correspondence. Additionally, he reportedly continued to drive his personal vehicle after that time, including driving to the November 2018 VA knee examination. Also, as noted at his December 2017 PTSD examination, the Veteran stated that he had worked as a transit driver from August 2015 to February 2016. The Board recognizes that the Veteran's lack of vision in the right eye would negatively impact his ability to obtain and maintain either a commercial or personal driver's license in most cases, but his reports of driving in both a personal and professional capacity for a large portion of the appeals period suggests that he may have qualified for an exemption. Moreover, even if accepting that the Veteran service-connected disabilities, specifically his vision render him unable to drive commercially and that his bilateral knee limitations and other musculoskeletal disabilities would prevent a return to work as a construction worker or laborer, the Board notes that the Veteran also has past experience working as a custodian in a hospital, an order filler, and a gas station service worker and, more recently, he volunteered at two VAMCs prior to the pandemic. The Veteran's GED and college classes would also assist with obtaining and maintaining such similar employment. Accordingly, while the Veteran's occupational impairments would cause some difficulty in most professions, there is no indication that he could not return to one of his prior professions, or a similar position, with reasonable accommodations, such as writing tasks down to combat his mild memory loss or limitations to lifting. Thus, the record does not show that the Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. TDIU is not warranted and his claim is denied. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.