Citation Nr: 22005282 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 15-05 700 DATE: February 1, 2022 ORDER Entitlement to service connection for an eye disability is denied. FINDING OF FACT A disability of either eye, other than refractive error, was not manifest in service and is not attributable to service. CONCLUSION OF LAW Service connection for an eye disability is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 4.9. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1952 to September 1954 and from October 1954 to November 1973. This matter comes to the Board of Veterans' Appeals (Board) from a June 2013 rating decision which, in pertinent part, found that new and material evidence had not been received to reopen a claim of entitlement to service connection for an eye disability. In December 2017, April 2020 and April 2021, the Board remanded the matter, most recently for a VA examination and medical opinion (the April 2020 Board decision also found that new and material evidence had been submitted to reopen the claim). Service Connection for an Eye Disorder The Veteran contends that he has a current bilateral eye disorder related to his military service. Specifically, in his February 2015 VA Form 9, the Veteran claimed that he was seen in the emergency room during service to remove paint from his left eye and that he has had vision problems ever since. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Generally, service connection may not be granted on a direct basis for refractive error of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable regulations. See 38 C.F.R. §§ 3.303(c), 4.9; see also Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003). However, service connection may be granted if the refractive error was subject to a superimposed disease or injury. See VAOPGCPREC 82-1990. Regarding hypermetropia, hyperopia, regular astigmatism and presbyopia, which are shown in the Veteran's treatment records and on examination, as discussed below; it is noted that these are findings of refractive error. Specifically, presbyopia is a visual condition that becomes apparent especially in middle age and in which loss of elasticity of the lens of the eye causes defective accommodation, and inability to focus sharply for near vision. McNeely v. Principi, 3 Vet. App. 357, 364 (1992). Presbyopia is "hyperopia and impairment of vision due to old age." Dorland's Illustrated Medical Dictionary 1349 (28th ed. 1994). Hyperopia is that error of refraction in which rays of light entering the eye parallel to the optic axis are brought to a focus behind the retina, as a result of the eyeball being too short from front to back. Called, also, farsightedness and hypermetropia." Dorland's Illustrated Medical Dictionary 797 (28th ed. 1994). Myopia is that error of refraction in which rays of light entering the eye parallel to the optic axis are brought to a focus in front of the retina. Dorland's Illustrated Medical Dictionary 1094 (28th ed. 1994). Astigmatism is due to unequal curvature of the refractive surfaces of the eye; hence a point source of light cannot be brought to a point focus on the retina, but is spread over a more or less diffuse area. Dorland's Illustrated Medical Dictionary 151 (28th ed. 1994). As an initial matter, the Board observes that the Veteran has current left and right eye disorders, diagnosed as bilateral corneal arcus, bilateral dermatochalasis, bilateral dry eye syndrome, right eye nuclear cataract, left eye intraocular lens and refractive errors, as evidenced by October 2020 and August 2021 VA examinations. Additionally, the Veteran's service treatment records (STRs) show that his eyes were clinically normal, and he reported no history of eye trouble or wearing glasses on enlistment examination in October 1954. Subsequent September 1958, March 1967 and October 1968 examinations are similarly silent for complaints of vision problems or diagnosis and treatment of refractive errors. In May 1969, the Veteran sought emergency treatment after paint remover accidently splashed in his left eye. Fluorescein staining showed no corneal defect, and the Veteran was diagnosed with chemical conjunctivitis. His eyes were thoroughly irrigated, he was prescribed sulfacetamide, and he was told to return if needed. An April 1970 ophthalmologic consultation reflects the Veteran was diagnosed with refractive error and prescribed glasses. A May 1972 vision examination also noted the Veteran was photophobic. The Veteran's May 1973 retirement examination report shows he denied a history of eye trouble and reported wearing glasses. On examination, evaluation of his eyes generally as well as ophthalmoscopic, pupils and ocular motility evaluations were clinically normal, the examiner noted he wore glasses for defective visual acuity and his corrected near and distant vision was 20/20 in each eye. Private treatment records show the first post-service treatment for eye complaints in the record was in April 1997, when the Veteran was noted to have cataract OS [left eye]. These records include an October 1998 note that the Veteran had "posterior subcapsular cataract OS. Had phacoemulsification and IOL [intraocular lens] OS on May 14, 1998." There were no complications and his postoperative visual acuity was 20/25. A June 1998 VA eye examination report notes the Veteran was "status post cataract surgery OS two weeks ago," his corrected near and far visual acuity in each eye was 20/25. The diagnoses were pseudophakia OS and early senile cataracts OD (right eye.). VA treatment records also include eye consultation reports and show findings of nuclear senile cataract, pseudophakia, hypermetropia, regular astigmatism and presbyopia included on the Veteran's problem list. A May 2017 report of eye consultation (with a May 2008 eye clinic note) shows diagnoses of refractive error, NS (nuclear sclerotic cataract) 2 right/pseudophakia left, dermatochalasis both eyes and arcus senilis both eyes. An October 2020 VA eye examination report shows diagnoses of eye conditions, other than congenital or developmental errors of refraction, listed as left eye intraocular lens (pseudophakia), right eye nuclear cataract, bilateral dermatochalasis and bilateral corneal arcus. The Veteran was also noted to have hyperopia and astigmatism with presbyopia. The examiner described dermatochalasis as "excess eyelid skin that causes the condition;" corneal arcus as "common in older adults," "caused by fat (lipid) deposits deep in the edge of the cornea" and "doesn't affect vision, nor does it require treatment;" right eye cataract as progressive and causing reduced visual acuity; and left eye intraocular lens (pseudophakia) as a "replacement of the intraocular crystalline lens." On examination, the Veteran's uncorrected distance visual acuity was 20/100 right and 20/70 left which was corrected to 20/40 right and 20/20 or better left. His uncorrected near visual acuity was 20/100 right and 20/70 left which was corrected to 20/40 right and 70/20 or better left. Based on interview and examination of the Veteran, review of the record and citing to medical literature, the examiner opined: (1) It is less likely than not that the right eye nuclear cataract is related to service, including the in-service chemical conjunctivitis and photophobia, because nuclear cataracts are age-related. The examiner noted that '"[n]uclear cataracts are often a normal progression of aging, as the lens of the eye can yellow and become cloudy with age," and "often impact distance vision." (2) It is less likely than not that the bilateral dermatochalasis is related to service, including the in-service chemical conjunctivitis and photophobia, because there is no evidence that this condition is associated with service. Dermatochalasis, "is defined as excess upper and/or lower eyelid skin. The eyelid skin is thin and prone to fine wrinkling. Redundant skin is often associated with fat herniation, the descent of eyebrows, and descent of mid-face. Fat herniation is most common in the superomedial region and in the inferomedial and central part. In addition, variable puffiness due to eyelid edema and discoloration from venous leakage (black circles under eyes) develop with age. It is a common condition and is seen in elderly persons, but occasionally in young adults also. It is more common in the upper eyelid but may be seen in the lower eyelids as well." (3) It is less likely than not that the bilateral corneal arcus is related to service, including the in-service chemical conjunctivitis and photophobia, because there is no evidence that this condition is associated with service. The examiner explained that "[c]orneal arcus, or arcus senilis, is most often an involutional change modified by genetic factors." (4) It is less likely than not the left eye intraocular lens (pseudophakia) is related to service, including the in-service chemical conjunctivitis and photophobia, because there is no evidence that this condition is associated with service. The examiner explained that the "intraocular lens is an eye replacement for crystalline lens removal" and the "surgery was not service related." Because the October 2020 examiner did not provide an opinion as to the Veteran's visual acuity, including whether there was aggravation or additional disability due to disease or injury superimposed upon such visual defect during service, and it is unclear whether, in the opinions provided, the examiner considered the June 1998 VA examination report showing diagnoses of left eye pseudophakia and right eye cataract; in April 2021, the appeal was remanded for a new VA examination and medical opinion. Accordingly, the Veteran underwent a VA examination in August 2021, at which time the aforementioned eye disorders were diagnosed as well as bilateral dry eye syndrome and, following a review of the record and interview and examination of the Veteran, the examiner opined that the diagnosed eye disorders were less likely than not incurred in or caused by an in-service injury, event, or illness. In addition to reiterating the aforementioned opinions and explanations, the examiner opined that dry eye syndrome is less likely as not incurred in or caused by service because "[t]his is an age-related condition in this Veteran." In addition, regarding refractive error, the examiner opined that it is less likely as not the Veteran suffered a superimposed injury or disease during service because his "refractive errors are a natural age-related condition." Further, after consideration of the Veteran's STRs, including the May 1969 incident when paint remover splashed into the Veteran's left eye and findings of refractive error and photophobia, as well as the June 1998 diagnosis of right eye cataract and left eye pseudophakia; the examiner opined that "blur vision and photophobia are common effects of the chemical burn, this condition receded and no permanent effect was suffered" and there are "no relations between the diagnoses of left eye pseudophakia and right eye cataract as early as June 1998." Upon consideration of the Veteran's description of his in-service injury and symptoms, post-service symptoms and his assertion that these symptoms represented the onset of his current disability, the examiner explained that "the medical records do not show a permanent photophobia-induced refractive error or other injury after the chemical splash of his left eye" and "the Veteran's conditions are age-related." The Board affords great probative weight to the combined October 2020 and August 2021 VA opinions because they are based on consideration of the pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed and relevant medical literature. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary. The Board also considered the Veteran's assertions as to the etiology of his eye disorders; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the ocular system, including the impact of paint remover splashed into the eye, a past episode of conjunctivitis and photophobia and progression of refractive error. Consequently, such matter may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's opinion as to the etiology of his eye disorders is not competent evidence and, consequently, is afforded no probative weight. Therefore, the Board finds that a refractive error of the left and/or right eye, including hypermetropia, hyperopia, regular astigmatism and presbyopia, was not subjected to a superimposed disease or injury during service that resulted in additional disability, and a left and/or right eye disorder other than a refractive error is not shown to be causally or etiologically related to any disease, injury, or incident during service. Consequently, service connection for such disorders is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the evidence is persuasively against the claim of service connection for an eye disorder. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for an eye disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K Hughes 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.