Citation Nr: 22012288 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 14-34 701A DATE: March 3, 2022 REMANDED Entitlement to service connection for an eye disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to August 1971, with service in Vietnam. The Veteran also had subsequent service with the Reserves. The issue comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his spouse, O. W., testified at a Board hearing in November 2018, before the undersigned Veterans Law Judge (VLJ), who held open the record for 90 days for the submission of additional evidence. A copy of the transcript is of record. This issue was thrice before the Board in May 2019, October 2020, and October 2021 and remanded. The most recent remand of October 2021 mandated that the RO provide the Veteran with a supplemental medical opinion addressing direct and secondary service connection. In November 2021, such opinions were procured. Nonetheless, as is indicated below, the opinions are again for the examiner failed to provide adequate rationales. Thus, there has not been substantial compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for an eye disorder is remanded. The Veteran contends that he has an eye disorder that was incurred in service or in the alternative, caused or aggravated by his service-connected diabetes mellitus, type II. During his November 2018 hearing, he and his wife competently and credibly testified that while in service, he was often hit in the "left eye area" by spent cartridges when firing weapons. Further, he intimated that when parachuting through the jungles of Vietnam his was poked in the eyes by trees that were treated with herbicide agents. The Veteran was afforded supplemental opinions in November 2021 addressing direct and secondary service theories of his claim. The examiner provided a negative nexus. In her opinion for service connection under the causation prong of the secondary claim, she explained that [t]he Veteran's cataracts and dry eye were less likely than not proximately due to or the result of his service-connected diabetes mellitus or coronary artery disease as there is no direct nexus between diabetes or coronary artery disease and dry eye syndrome. [His] cataract is defined as mild nuclear, which is most likely due to the natural aging process and not the cortical type which is commonly due to diabetes. Dry eye syndrome is an ocular surface disorder that is most likely due to poor environmental air quality conditions and not due to diabetes or coronary artery disease. The Veteran's representative has argued that the rationale is incomplete since the examiner failed to acknowledge that cataracts, "not just cortical cataracts," are indeed often a result of diabetes mellitus type II and that the Veteran may have suffered complications of diabetes many years before the actual diagnosis. In support thereof, he cited the results from the 2019 National Institute of Health study, which found that diabetes mellitus can affect all ocular structures, and increased levels of glycated hemoglobin were demonstrably associated with an increased risk of nuclear and cortical cataracts. Additionally, cited was the research from The Journal of Ophthalmic & Vision Research, found that cataracts are one of the most common causes of visual impairment, among the earliest complications of diabetes mellitus, and remain the leading cause of blindness, affecting approximately 18 million people. Cataracts occur at an earlier age and are 2-5 times more frequently in patients with diabetes. As the findings of the above studies were not addressed by the examiner in her decision, a remand is again warranted. Accordingly, the matter is REMANDED for the following action: 1. Provide the Veteran's claims file to a suitable clinician to provide a supplemental opinion for the Veteran's eye disability. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. November 2018 Board testimony. b. Articles provided by the Veteran's representative: i. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422859/ ii. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3589218/ The examiner must provide opinions as to the following: a. Whether it is at least as likely as not that the Veteran's cataracts and dry eyes began during active service, or is related to service, to include: i. being hit in the "left eye area" by spent cartridges while firing weapons, an/or ii. due to poked in the eyes by trees treated with herbicide agents trees while parachuting through the jungles of Vietnam. It is not sufficient to provide a negative opinion regarding herbicides because cataracts are not on the list of diseases and conditions presumptively associated with exposure to herbicides. b. Whether it is at least as likely as not that the Veteran's cataracts and dry eye were proximately due to or the result of his service-connected diabetes mellitus and/or CAD. c. Whether it is at least as likely as not that his cataracts and dry eye were aggravated beyond their natural progression by his service-connected diabetes mellitus and/or CAD. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 2. Then, adjudicate the claim. If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case (SSOC) and allow the applicable time for response. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.