Citation Nr: 22010802 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 16-21 901 DATE: February 24, 2022 REMANDED Entitlement to service connection for myopia and a saccadic eye movement disorder, to include as secondary to a traumatic brain injury (TBI), is remanded. Entitlement to service connection for a right forearm disability, status post laceration to the brachioradialis muscle, pronator teres muscle, and common flexor origin, as secondary to service connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from December 2003 to May 2008. These matters come before the Board of Veteran's Appeals (Board) on appeal from a January 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). (CONTINUED ON NEXT PAGE) 1. Entitlement to service connection for myopia and a saccadic eye movement disorder, to include as secondary to a TBI The Veteran contends that he has myopia and a saccadic eye movement disorder ("rapid eye movement disorder") due to his active duty or as secondary to his service connected TBI. His enlistment examination shows uncorrected visual acuity was 20/60 in the right eye, and 20/20 in the left eye. See STR, June 2008 at p.19 of 44. Mild myopia was diagnosed. In December 2003, uncorrected visual acuity was 20/40 on the right and 20/50 on the left. No separation examination report is found in the service treatment records. However, in a May 2008 medical history questionnaire and medical assessment, the Veteran denied any eye trouble or disorder, denied memory loss or amnesia, and denied any head or other unreported injury. Because myopia was noted on entry into service, the presumption of soundness with regard to the claimed myopia has been rebutted. See 38 U.S.C. § 1111. Although there is no record of any TBI in the service treatment records, nevertheless, the Veteran is presently service connected for a TBI he reported occurred in 2006 aboard the USS Abraham Lincoln due to falling down a ladder and hitting his head. See Rating decision, February 2018; VA examination (TBI), November 2017 at p.2 of 11, and at p.3 of 8. A December 2015 VA optometry record shows the Veteran reported difficulty focusing since a TBI in 2006. Near point stress/saccadic dysfunction, and symptomatic for eye strain was diagnosed, and it was noted as longstanding since a TBI in 2006. See CAPRI, received January 2016 at p.8. The Veteran has not been afforded a VA examination relating to his claim. As there is evidence of a diagnosed saccadic eye dysfunction in VA optometry records, which records notes a history of a TBI, the Board finds the claim should be remanded so that the Veteran may be afforded a VA examination. 2. Entitlement to service connection for a right forearm disability, status post laceration to the brachioradialis muscle, pronator teres muscle, and common flexor origin, as secondary to service connected PTSD The Veteran also contends that he has a right forearm disability due to an attempted suicide in 2009 caused by his service connected PTSD. The Board acknowledges that VA psychology records show the Veteran reported he attempted suicide in 2009 by cutting his arm down to the bone. See id. at p.30 and 110-111. A February 2009 private operative report shows surgical treatment for laceration to the brachioradialis, pronator teres, and common flexor origin (right). See SSA records, March 2016 at p.44 of 45. March 2009 VA treatment records document a healing right forearm laceration and cast. See CAPRI, received January 2016 at p.133 and 136 of 141. There is no medical opinion of record addressing whether the Veteran currently has any residual right forearm disability due to the 2009 laceration, and if so, whether the attempted suicide was due to his service connected PTSD. The Board acknowledges that the Veteran was treated for a right forearm laceration in 2009, and the Veteran's personal account of his attempted suicide. However, to date, no VA examination has been performed to address whether there is residual right forearm disability, and if so, whether the suicide attempt was caused specifically by the Veteran's service connected PTSD. Therefore, the claim must be remanded so that a VA examination may be provided to address whether the Veteran has residual disability of the right forearm due to an attempted suicide by laceration caused by his service connected PTSD. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination to address the nature and etiology of his claimed myopia and saccadic eye dysfunction. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner should opine as follows: a) For each eye, whether the Veteran had myopia on entry into service note that the enlistment examination notes mild myopia, and notes 20/60 uncorrected vision in the right eye - see STR, June 2008 at p.19 of 44; b) If myopia was shown on entry into service but did not increase during service, the examiner should opine whether it is "at least as likely as not" that the myopia was aggravated by his active service; c) If myopia was shown on entry into service but did increase during service, whether there is "clear and unmistakable evidence" that it was not aggravated by his active service; d) For each eye in which myopia was not shown on entry into service, whether it is "at least as likely as not" that the myopia was caused by the Veteran's active service; e) Whether it is "at least as likely as not" that any saccadic eye dysfunction was caused by the Veteran's active service; f) For the Veteran's claimed myopia and saccadic eye dysfunction, whether it is "at least as likely as not" that it was caused or aggravated by service connected TBI (note that regardless of whether a TBI is shown in the service treatment records, the Veteran is service connected for a TBI he reported from 2006 hitting his head in a fall down stairs). Any opinion must be accompanied by a complete rationale. 2. Afford the Veteran a VA examination to address the nature and etiology of his claimed right forearm disability, status post laceration to the brachioradialis muscle, pronator teres muscle, and common flexor origin. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner should opine as to whether the Veteran has any residual right forearm disability resulting from the February 2009 laceration shown in the records, including but not limited to any residual scar see SSA records, received March 2016 at p.44 of 45. If residual right forearm disability is shown on exam, the examiner should opine whether it is "at least as likely as not" that the Veteran lacerated his right forearm in February 2009 attempting suicide due to his service connected PTSD. Any opinion must be accompanied by a complete rationale. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Juliano, 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.