Citation Nr: 22060003 Decision Date: 10/26/22 Archive Date: 10/26/22 DOCKET NO. 18-41 958 DATE: October 26, 2022 ORDER 1. Entitlement to service connection for peripheral edema in both lower extremities, to include venous insufficiency and to include as secondary to bilateral total knee replacement, is denied. 2. Entitlement to service connection for bilateral pes planus is denied. 3. Entitlement to service connection for a bilateral hearing loss disability is denied. REMANDED 4. Entitlement to a disability rating in excess of 30 percent for right total knee replacement is remanded. 5. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected disabilities, is remanded. 6. Entitlement to service connection for glaucoma as secondary to the receipt of steroid injections to the service-connected bilateral total knee replacement is remanded. 7. Whether new and material evidence has been received to reopen the claim for service connection for a lumbar spine disability, to include as secondary to service-connected disabilities, is remanded. 8. Entitlement to an effective date earlier than April 29, 2021 for the award of a total disability rating for compensation based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Peripheral edema in the lower extremities/feet did not have its onset during service and is not otherwise related to service and is not caused or aggravated by bilateral total knee replacement. 2. Bilateral pes planus did not have its onset during service and is not otherwise related to service. 3. The Veteran does not have a bilateral hearing loss disability for VA purposes. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a peripheral edema, to include venous insufficiency and to include as secondary to service-connected bilateral total knee replacement, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1980 to April 1986. In a September 1987 Administrative Decision, VA noted that Veteran's discharge from the military for the period of service from March 1983 to April 1986 was deemed dishonorable due to drug abuse. VA concluded that the Veteran's actions were not considered to have willful and persistent. Therefore, VA considered the Veteran's discharge to have been issued under other than dishonorable conditions and allowed for the Veteran to be entitled to all VA benefits. In April 2021, the Veteran testified before the undersigned Veterans Law Judge before the Board of Veterans' Appeals (Board). During the Board hearing, the undersigned stated that a claim for TDIU would be added to the Veteran's appeal due to his claim for increase involving the right total knee replacement, wherein he alleged that he was unable to work due to, in part, the right knee replacement. However, in a June 2021 rating decision, the Regional Office granted TDIU, with an effective date of April 29, 2021. The Board finds this is a partial grant of the Veteran's claim and has characterized the issue as entitlement to an effective date earlier than April 29, 2021 for the award of a TDIU rating. Additionally, at the April 2021 hearing, the undersigned accidentally characterized the issue involving the lumbar spine as entitlement to service connection for a lumbar spine disability versus recognizing that the claim had been previously denied in a September 2013 rating decision. The Board apologizes for the oversight. Thus, the issue has been properly characterized as one that was previously denied. Generally, the Board may not consider additional evidence added to the file that was not previously reviewed by the Agency of Original Jurisdiction (AOJ) unless a waiver of initial AOJ review is obtained from a claimant. In December 2021, the Board sent a letter to the Veteran indicating that additional evidence had been added to the file after the June 2018 and May 2019 Statements of the Case (SOC), which comprised of VA treatment records, VA examination report, and SSA records. The Board informed him the evidence had not been considered by the AOJ and that he had the right to have the AOJ review the evidence before the Board reviewed it, but that he could submit a waiver in writing that would allow the Board to review the evidence in the first instance. The Board received a response from the Veteran in January 2022 to remand the claims to the AOJ to consider the new evidence relevant to the claims. The new evidence is relevant to the Veteran's claims for an increased disability rating for the right total knee replacement and service connection for cervical spine disability, a lumbar spine disability, and an eye disability. The Board finds that the new evidence added to the file since the June 2018 and May 2019 SOCs is not relevant to the Veteran's service-connection claims for peripheral edema of the bilateral lower extremity, bilateral pes planus, and bilateral hearing loss disability, as the evidence does not establish a nexus to service or that the Veteran has a current bilateral hearing loss disability for VA purposes. In other words, these records are not pertinent to these three claims. Therefore, the Board finds a remand is not necessary for these three claims and will consider them on the merits. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis and sensorineural hearing loss, which the latter diagnosis is an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disability. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence of record. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, regarding the Veteran's claims on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. 1. Entitlement to service connection for peripheral edema of the bilateral lower extremity, to include venous insufficiency The Veteran contends his peripheral edema had its onset during service. During the Board hearing, the Veteran testified that he experienced pain and swelling on the bottom of his foot during service. He also said that when he was in service, he was training a lot and the training was tough. The Veteran testified that the sneakers he wore in the service would bust on his feet and the boots had no arch support. After carefully reviewing the evidence of record, the Board finds that the evidence persuasively weighs against a finding that peripheral edema had its onset in service or is caused or aggravated by the service-connected total right and/or total left knee replacements. The reasons follow. As to the first element of a service-connection claim, a current disability, the Board finds that a May 2018 VA examination report shows that the Veteran was diagnosed with peripheral edema with venous insufficiency in the lower extremities. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, service treatment records do not document a disease or injury in service indicative of peripheral edema in service. Although the Veteran contends that he experienced peripheral edema since 1985, which would be during service, the Board affords more probative value to what is documented within the Veteran's service records that do not show reports of peripheral edema during service. The Veteran was seen throughout service for multiple medical complaints, including his knees, a fibula fracture, sore throat, genitourinary complaints, and other medical symptoms. What is not documented in the service treatment records are complaints involving his feet. The Veteran underwent surgery on the right knee in May 1985. While considering the Veteran's fitness for duty in the U.S. Navy, the Veteran testified during the February 1986 Administrative Discharge Board that his medical problems were restricted to his knees. He did not report peripheral edema during this hearing. The Veteran's testimony was provided under oath, and the Board finds that what the Veteran reported at that time while under oath is credible, as he described how he twisted his right knee and tore a ligament, reinjured his knee, and then sprained the other knee. Had the Veteran experienced other medical problems that were impacting his ability to perform his duties, the Board finds he would have reported other medical problems. As such, the Board finds that the Veteran's subsequent lay statements regarding an in-service peripheral edema conflict with his February 1986 sworn testimony and the service treatment records and his statements are, therefore, not credible. Thus, the evidence is against a finding that the second element of a direct service-connection claim requiring an onset in service is not met. There is also a lack of evidence of a nexus between the post-service diagnosis of peripheral edema and service. For example, the Veteran underwent a VA examination in January 1989. When asked about his present medical complaints, the Veteran reported that both knees continued to get worse. He described constant pain in his knees, that his right knee continued to pop, and that both knees had a grinding sensation. He stated that his height had decreased two inches because of his knees. The Veteran had a physical examination of multiple body systems, including the musculoskeletal system, and no peripheral edema was observed or reported. The Board finds this is evidence that the Veteran's statements that his peripheral edema having its onset during service is not credible, as he did not report such symptoms when documenting his present complaints. A February 2002 private treatment record shows that the Veteran had undergone an arthroscopy on his left knee in November 2001. The examiner documented that the Veteran had no effusion. Additionally, of record are VA and private treatment records from 2011 to 2014, which do not document peripheral edema. A December 2011 private treatment record shows that the Veteran was undergoing a cardiac clearance for knee surgery and a colonoscopy. When listing the Veteran's active medical problems, the examiner documented coronary artery disease, hyperlipidemia, and hypertension. What was not listed was peripheral edema. The Veteran's lower extremities were physically examined, and the examiner documented they were normal. When seen at VA in June 2012, the examiner documented the Veteran's past medical history as including coronary artery disease, hypertension, and bilateral anterior cruciate ligament rupture in service. The Veteran presented for a physical. The examiner wrote that the general state of his health was "good," but that he was disturbed by progressive knee pain. The Board finds that the Veteran's failure to discuss ongoing or intermittent peripheral edema at the time of his physical examination to be indicative of his not having such symptom, as he had the wherewithal to report bilateral knee symptoms and his past medical history, which did not include peripheral edema. The Veteran was presenting for a physical examination, where the purpose is to address one's overall health. In such circumstances, it is logical to assume that the Veteran would report medical concerns he was having or experiencing, since he reported ongoing bilateral knee pain, which is consistent with the evidence in the claims file. At this point, it had been more than 20 years since service discharge, and if the Veteran had been experiencing chronic peripheral edema for decades, he would have reported such fact. Thus, the Board finds that the allegation of chronic peripheral edema in the years following service discharge is not credible. This is further supported in a December 2014 private treatment record, where the examiner documented the Veteran's past medical history of coronary artery disease, hyperlipidemia, hypertension, and knee pain. The examiner performed a physical examination, and the extremities were documented to be normal, atraumatic, with no cyanosis or edema. Thus, edema was specifically refuted. This is evidence against a finding that peripheral edema had its onset in service. Without evidence of a disease or injury in service and a nexus between the post-service peripheral edema and service, direct service connection is not warranted. As to secondary service connection, the Veteran is service connected for bilateral total knee replacement and, thus, the second element of a secondary service-connection claim is met. As to evidence of a nexus between the Veteran's peripheral edema and the bilateral knee replacement, the Board finds that the evidence persuasively weighs against a nexus. For instance, the May 2018 VA examiner concluded that the Veteran's peripheral edema with venous insufficiency was not caused by or a result of the service-connected knee disabilities. The examiner explained that venous insufficiency was not a complication of having a total knee arthroplasty. Instead, she wrote peripheral edema normally is linked to heart, kidney, or liver dysfunction or disease. The examiner noted that while the Veteran has swelling in both lower legs, he stated during the examination that the edema started in 1985, and the evidence shows that the Veteran had a left knee replacement in 2015 and right knee replacement in 2017. Therefore, the examiner concluded that peripheral edema is less likely than not (less than 50 percent probability) proximately due to or the result of the claimant's service-connected disabilities. While the examiner did not specifically use the word "aggravate" or "aggravated," the Board finds that the opinion is distinguishable from the holding in El-Amin v. Shinseki, 26 Vet. App. 136 (2013). In that case, the U.S. Court of Appeals for Veterans Claims found that the examiner's opinion that it was "more likely than not that the veteran's alcohol abuse was related to factors other than the veteran's post-traumatic stress disorder" did not rule out the possibility that the veteran's service-connected posttraumatic stress disorder aggravated his alcohol abuse to some degree. Id. In contrast, here, the May 2018 examiner opined that "venous insufficiency is not a complication of having a total knee arthroplasty." Because the examiner clearly opined that there was no medical relationship between the service-connected bilateral knee replacement and the peripheral edema, the examiner's statement, unlike that of the examiner in El-Amin, rules out the possibility that the service-connected disability may aggravate to some degree the non-service-connected peripheral edema. Thus, the Board finds that the examiner's opinion addressed both causation and aggravation and is, therefore, probative regarding whether the service-connected disability aggravated the peripheral edema. In light of the VA examiner's review of the Veteran's symptoms and discussion of the etiology of his peripheral edema that applied medical principles, the Board affords this opinion probative value and finds that it is evidence against peripheral edema not being caused or aggravated by the service-connected bilateral knee replacement. At the present time, there is no competent evidence of a nexus between the post-service diagnosis of peripheral edema and service. There is also no competent evidence of a nexus between peripheral edema and the service-connected bilateral knee replacement to weigh against the May 2018 medical opinion. The Veteran does not have the medical expertise to attribute the peripheral edema to the service-connected bilateral knee replacement. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for peripheral edema, to include venous insufficiency and to include as secondary to service-connected bilateral total knee replacement, is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 2. Entitlement to service connection for bilateral pes planus The Veteran contends his bilateral pes planus had its onset during service. During the Board hearing, the Veteran testified that he experienced pain and swelling on the bottom of his foot. He stated that his bilateral pes planus was observed all throughout his service record. He also said that when he was in service, he was training a lot and the training was tough. The Veteran also stated that the sneakers he wore in the service would bust on his feet and the boots had no arch support. After carefully reviewing the evidence of record, the Board finds that the evidence persuasively weighs against a finding that bilateral pes planus had its onset in service. The reasons follow. As to evidence of a current disability, the February 2019 VA examination shows a diagnosis of bilateral pes planus (flat feet). Thus, the facts establish that the first element of a service-connection claim is met. As to evidence an in-service disease or injury, service treatment records do not document complaints, treatment, or diagnosis of bilateral pes planus or a disease or injury indicative of bilateral pes planus in service. The Veteran complained of pain to the lateral aspect of the left talus in June 1983. An x-ray was taken at that time revealed no fracture. The x-ray did not document pes planus. The talus is a part of the ankle, and not the bottom of the foot. https://www.merriam-webster.com/dictionary/talus. Thus, the Board does not find that this is evidence of a disease or injury involving the bottom of the foot. Additionally, although the Veteran asserts that his bilateral pes planus had an onset during service, the Board affords more probative value to what is documented within the Veteran's service records that do not show reports of bilateral pes planus during service. For instance, during the June 2017 VA examination, the Veteran stated that he has had pain since 1981 but the onset of his foot symptoms happened in 1985. He reported the disability occurred from wear and tear and he felt pins and needles in the bottom of his feet but was not seen or treated at the time. However, the Veteran was seen throughout service for multiple medical complaints, including his knees, a fibula fracture, sore throat, genitourinary complaints, and other medical symptoms. What is not documented in the service treatment records are complaints involving his feet. While considering the Veteran's fitness for duty in the U.S. Navy, the Veteran testified during the February 1986 Administrative Discharge Board that his medical problems were restricted to his knees. No bilateral pes planus was noted during this hearing. The Veteran's testimony was provided under oath, and the Board finds that what the Veteran reported at that time while under oath is credible, as he described how he twisted his knee and tore a ligament, reinjured his knee, and sprained the other knee. As such, the Board finds that the Veteran's subsequent lay statements regarding an in-service bilateral pes planus conflict with his February 1986 sworn testimony and are, therefore, not credible. Thus, the evidence is against a finding that the second element of a direct service-connection claim requiring an onset in service is not met. There is also a lack of evidence of a nexus between the post-service diagnosis of bilateral pes planus and service. The Veteran had a VA examination in January 1989. When asked about his present medical complaints, the Veteran reported that both knees continued to get worse. He described constating pain in his knees, that his right knee continued to pop, and that both knees had a grinding sensation. He stated that his height had decreased two inches because of his knees. The Veteran had a physical examination of his musculoskeletal system, and no bilateral pes planus was documented or reported. The Board finds this is further evidence that the Veteran's statements that his bilateral pes planus had its onset during service is not credible. A February 2002 private treatment record from an orthopedic clinic shows that the Veteran had undergone an arthroscopy on his left knee in November 2001. The examiner wrote that the Veteran reported that he had gotten back to work and was on his feet "more and more" and that the more he was on his feet, his left knee hurt. Thus, while discussing being on his feet more, the Veteran complained of left knee pain. If the Veteran had been experiencing bilateral foot pain, the Board finds he would have reported it at that time, as he was seeing an orthopedic physician, and talked about being on his feet, but discussed left knee pain only as a result of being on his feet. The Veteran saw the orthopedist regularly from February 2002 to April 2002 (approximately eight times), and he did not report bilateral foot pain. Additionally, of record are VA and private treatment records from 2011 to 2013, which do not document peripheral edema. A December 2011 private treatment record shows that the Veteran was undergoing a cardiac clearance for knee surgery and a colonoscopy. When listing the Veteran's active medical problems, the examiner included coronary artery disease, hyperlipidemia, and hypertension. What was not listed was bilateral pes planus. When seen at VA in June 2012, the examiner documented the Veteran's past medical history as including coronary artery disease, hypertension, and bilateral anterior cruciate ligament rupture in service. The Veteran presented for a physical. The examiner wrote that the general state of the Veteran's health was "good," but that he was disturbed by progressive knee pain. The Board finds that the Veteran's failure to discuss ongoing or intermittent bilateral foot pain at the time of his physical examination to be indicative of his not having such symptom, as he had the wherewithal to report bilateral knee symptoms. The Veteran was presenting for a physical examination, where the purpose is to address one's overall health. In such circumstances, it is logical to assume that the Veteran would report medical concerns he was having or experiencing, since he reported ongoing bilateral knee pain. At this point, it had been more than 20 years since service discharge, and if the Veteran had been experiencing chronic pain from bilateral pes planus for decades, he would have reported such fact, which is evidence against a nexus to service. The first evidence of a diagnosis of pes planus in the treatment records is in October 2014, which is more than 25 years following service discharge, and is evidence against the Veteran having bilateral pes planus that had its onset in service or is otherwise related to service. In a February 2019 medical opinion, an examiner found that it was less likely than not that pes planus had its onset in service. The examiner noted that the service entrance examination did not note pes planus, and there was no separation examination and no records of pes planus during service. The examiner checked the box that said that the disability was less likely than not related to service. The examiner's medical opinion is based on the same facts that the Board finds are accurate, which is that the Veteran did not have pes planus during service. Thus, the Board finds the February 2019 medical opinion probative. Without evidence of a disease or injury in service and a nexus between the post-service bilateral pes planus and service, direct service connection is not warranted. There is no competent evidence of a nexus between the post-service diagnosis of bilateral pes planus and service to weigh against the negative VA opinion. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for bilateral pes planus is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine is therefore not for application. Lynch, 21 F.4th 776. 3. Entitlement to service connection for a bilateral hearing loss disability The Veteran contends that his bilateral hearing loss disability had its onset during service. In a December 2018 statement, the Veteran stated that he experienced a hearing issue since being deployed on various U.S. Naval amphibious ships. At his Board hearing, the Veteran testified that he worked 12 hours a day where aircraft was constantly taking off, landing, and his rack was located right underneath the platform where the planes took off. Additionally, he said that his rack was on the port side, where the anchor was, and the chain would slam against the bulkhead. For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Board has carefully reviewed the evidence of record and finds that the evidence persuasively weighs against the claim for service connection for bilateral hearing loss disability. The reasons follow. The evidence shows that the Veteran does not have a current diagnosis of a bilateral hearing loss disability for VA purposes and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a), (d). For example, a February 2019 VA audiological evaluation showed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 30 20 20 LEFT 20 25 25 25 25 Speech discrimination score revealed speech recognition ability of 100 percent in the right and left ears. The examiner stated that the test results were valid. The examiner concluded that the Veteran had normal hearing. The February 2019 VA audiogram does not support that the Veteran has an auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz at 40 decibels or greater, or that a measurement of auditory thresholds for at least three of these frequencies that was 26 decibels or greater. He also had 100 percent speech discrimination in both ears. Accordingly, the evidence does not support that the Veteran has a bilateral hearing loss disability for VA purposes. Additional VA medical treatment records show that the Veteran was found to not have hearing loss. For instance, a November 2018 VA hearing evaluation showed that the Veteran had normal hearing in his right and left ears. The evidence persuasively weighs against a finding of bilateral hearing loss disability for VA purposes. Service connection is predicated on the existence of a current disability for VA purposes. At present, there is no competent evidence of record that establishes the existence of bilateral hearing loss disability under the requirement of 38 C.F.R. § 3.385. The United States Court of Appeals for Veterans Claims (Court) has specifically upheld the validity of 38 C.F.R. § 3.385 to define hearing loss for VA compensation purposes. Laypersons are sometimes competent to provide opinions regarding etiology and diagnosis. In this case, the Board finds that the specific audiological results shown on examination are more probative evidence as to whether the Veteran manifests a bilateral hearing loss disability for VA purposes. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131. Evidence must show that the Veteran currently has the disability for which benefits are being claimed. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a bilateral hearing loss disability is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v, 21 F.4th 776. REASONS FOR REMAND 4. Entitlement to a disability rating in excess of 30 percent for right total knee replacement 5. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected disabilities 6. Whether new and material evidence has been received to reopen the claim for service connection for a lumbar spine disability, to include as being secondary to service-connected disabilities As noted above, the Veteran requested his claims be remanded to the AOJ to consider the new evidence relevant to the claims. As such, the Board must remand the claims because pertinent evidence was associated with the claims file since the issuance of the statement of the case (SOC) in June 2018 for a disability rating in excess of 30 percent for right total knee replacement and in May 2019 for service connection for a cervical spine disability and lumbar spine disability. Specifically, VA treatment records, VA examination, and Social Security Administration (SSA) records obtained by the VA were added to the Veteran's claims file. 7. Entitlement to service connection for glaucoma, to include as being due to steroid injections involving the bilateral knee replacement The Veteran asserts that glaucoma was caused by the steroid injections he received in his right and left knees. At the April 2021 Board hearing, the Veteran testified that his sister is a physician in Pennsylvania, and she warned him to watch out when getting his steroid injections because it could cause glaucoma. The Veteran also submitted an article discussing a possible link between steroid injections and glaucoma. The Veteran was provided a VA examination related to his eye disability in February 2019. The examiner found that the Veteran's glaucoma was less likely than not proximately due to or the result of his service-connected status post-surgical scar of the left knee. However, the Board finds the opinion inadequately addresses whether glaucoma is secondary to steroid injections in his knees. Therefore, a remand is necessary to obtain an adequate secondary opinion. 8. Entitlement to an effective date earlier than April 29, 2021 for the award of TDIU The claim for entitlement to an effective date prior to April 29, 2021 for a TDIU rating is inextricably intertwined with the issue of entitlement to a disability rating in excess of 30 percent for right total knee replacement. As such, the Board's consideration of the merits of the Veteran's earlier effective date for a TDIU rating is deferred pending adjudication of the Veteran's claim for an increased disability rating for right total knee replacement. The matters are REMANDED for the following action: 1. Refer the claims file to an appropriate clinician to provide an opinion as to whether the Veteran's current glaucoma is related to steroid injections the Veteran's received in his service-connected bilateral knee disability. The examiner should review the file If the examiner believes that an in-person examination is needed to provide an informed opinion, then schedule an examination. The agency of original jurisdiction must provide a copy of the below facts to the examiner. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from February 1980 to April 1986. In 2002, the Veteran underwent five Hyalgan injections in the left knee. See VBMS entry with Document Type, "Medical Treatment Record Non-Government Facility," receipt date 05/01/2017. In August 2016, the Veteran received steroid injections in his right knee. The Veteran is service connected for bilateral total knee replacement. He underwent left knee replacement surgery in January 2015 and right knee replacement surgery in March 2017. The Veteran was diagnosed with possible early glaucoma of the right eye in December 2015. See VBMS entry with document type, "CAPRI," receipt date 02/11/2019, p. 592. A September 2018 VA treatment record shows the optometrist entered an assessment of high risk open angle glaucoma (OAG) suspect OS. The optometrist noted that the Veteran had a positive family history in his grandfather, and a history of cortisone injections for the knees for every six months for approximately five years. The optometrist also noted likely "[low tension glaucoma] but history of steroid knee injections." See VBMS entry with document type, "CAPRI," receipt date 02/28/2019, with "#1" in the subject field, pp. 68-69. An October 2018 VA treatment record shows that the same optometrist explained previous findings, prognosis, and management of low tension glaucoma mild OS, low risk OD. The optometrist stated that he "doubt[ed] knee injections caused unknown [intraocular pressure] response." See VBMS entry with document type, "CAPRI," receipt date 02/28/2019, with "#1" in the subject field, p. 68. In a December 2018 statement, the Veteran stated that since 2005, he has been experiencing vision ailments in his left eye. He said that the optometrist determined that he was experiencing an initial stage of glaucoma and associated that the steroid shots of his knee pain were a secondary source of his glaucoma. See VBMS entry with document type, "Correspondence," receipt date 12/30/2018, p. 2. A February 2019 VA examination report shows that the Veteran was diagnosed with open angle glaucoma, dry eye syndrome, and incipient senile cataracts. See VBMS entry with document type, "C&P Exam," receipt date 03/01/2019, with "DBQ OPHTH Eye" in the subject field. The February 2019 VA optometrist concluded that the Veteran's glaucoma was less likely than not proximately due to or the result of the service-connected knee disabilities. The optometrist stated The Veteran's glaucoma is less likely than not proximately due to or the result of his service-connected status post-surgical scar, left knee. The optometrist explained there is no medical evidence that surgery to the knee or surgical scar of the knee would cause glaucoma. Glaucoma seen on examination this date is at least as likely as not primary in nature with family history of glaucoma and deep cup/disc ratio with exacerbation and/or secondary causation by long-term steroid use. Medical records do show history of long-term steroid injections to the knee and Veteran verbally reported steroid tablets taken. There is medical evidence of steroid use causing glaucoma, but October 2018 examiner opined "doubt knee injections caused unknown IOP response." Upon examination, Veteran was diagnosed with open angle glaucoma OU, dry eye syndrome OU, and incipient senile cataracts OU. It is less likely than not veteran's glaucoma is proximately due to status-post surgical scar on the left knee. See VBMS entry with document type, "C&P Exam," receipt date 03/01/2019, with "Eye Opinion" in the subject field, p. 3. The February 2019 optometrist seemed to imply that the Veteran's glaucoma could have been secondary to steroid injections, but then concluded it was less likely than not. Thus, the Board is seeking an addendum opinion. At an April 2021 Board hearing, the Veteran testified that his sister is a physician and when he told her he was getting steroid injections for his knee pain, she warned him to be careful because it could cause glaucoma. See VBMS entry with Document Type, "Hearing Transcript," receipt date 04/16/2021, pp. 9-10. In May 2021, the Veteran submitted an article entitled, "Steroids and Glaucoma: What's the Connection?" See VBMS entry with document type, "Correspondence," receipt date 05/14/2021, pp. 3-4. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. After a review of the file, the examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: a) Is the Veteran's glaucoma caused by the steroid injections to his knees? Please state upon what facts, medical principles, and/or medical literature support the opinion. b) If the answer to a) is negative, has the Veteran's glaucoma been aggravated by the steroid injections to his knees? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the examiner finds that the steroid injections aggravated the Veteran's glaucoma, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the glaucoma prior to aggravation. If the examiner is unable to establish a baseline for glaucoma prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale, including reference to supporting clinical data and/or medical literature as deemed appropriate, must be provided for all medical opinions given. 2. The agency of original jurisdiction is asked to please review the medical opinion to ensure that the examiner answered the questions. Many times, when seeking a secondary opinion, the examiner will forget to address the "aggravation" portion. An "aggravation" opinion is not needed if causation is positively established. 3. The AOJ may perform any development it deems warranted. 4. Readjudicate the claims of entitlement to a disability rating in excess of 30 percent for right total knee replacement, service connection for a cervical spine disability, and whether new and material evidence has been received to reopen the claim for service connection for a lumbar disability in light of the new evidence associated with the claims file since the issuance of the June 2018 and May 2019 SOCs. The AOJ should also consider whether TDIU is warranted prior to April 29, 2021. If any benefits sought on appeal remain denied, a supplemental statement of the case (SSOC) should be furnished to the Veteran and his representative. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Griffin, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.