Citation Nr: 22014245 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 17-25 057 DATE: March 11, 2022 REMANDED Entitlement to service connection for a bilateral eye disability is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to April 1972, with additional service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This case was remanded in July 2018 and July 2020 for further development; it has since been re-assigned to the undersigned Veterans Law Judge. After reviewing the evidence of record, the Board has recharacterized the issue of service connection for bilateral glaucoma to encompass any bilateral eye disability. See generally Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). 1. Entitlement to service connection for bilateral narrow angle/closure glaucoma is remanded. An August 2019 VA eye examiner diagnosed bilateral narrow angle glaucoma, dry eye syndrome, blepharitis, and nuclear sclerosis cataracts. He opined that the Veteran's uncontrolled narrow angle glaucoma was the cause for his visual impairment, and that the other disabilities were not related to diabetes but were more age related: "All of these conditions are less as likely as not secondary to the [V]eteran's diabetes mellitus type II." He further opined, in a confusing fashion, that the Veteran's eye diagnosis (other than glaucoma) were "less as likely as not, incurred in or caused by current glaucoma related to service during service" and concluded that such were more "age-related." The examiner continued that the Veteran's glaucoma was getting worse due to his uncontrolled intraocular pressure and that it was less likely due to service since the condition developed many years after service and there is no relationship between "glaucoma and agents exposed by the [V]eteran." A December 2021 VA eye examiner diagnosed bilateral closure angle glaucoma, dermatochalasis, corneal arcus, pterygium, nuclear sclerosis, and dry eye syndrome. The examiner opined that the Veteran's dermatochalasis, nuclear sclerosis, and dry eye syndrome were "age-related" and not related to his service-connected diabetes. The Veteran's glaucoma was becoming worse due to uncontrolled intraocular pressure; such was not related to service since the condition developed many years post service and there is no relationship between "glaucoma and agents exposed by the [V]eteran." The Board finds these opinions inadequate as they do not adequately address causation and aggravation with respect to the Veteran's service-connected diabetes. Additionally, in light of a June 2016 VA treatment record that includes a diagnosis for bilateral ocular hypertension and the VA examiners' opinions that the Veteran's glaucoma was becoming worse due to uncontrolled intraocular pressure, and the Veteran's service-connected hypertension, an additional secondary opinion is required. The Veteran's VA treatment records contain multiple notes indicating that relevant documents, including those involving eye treatment, have been scanned into VistA Imaging. See VA treatment records from August 2018 (referring to a diabetic retinal examination); September 2021 (community care consult) and October 2021 (being seen at Rio Pedras Medical Center for complaints of headaches with blurred vision). The Board is not able to access records scanned into VistA Imaging and a remand is unfortunately required to obtain these records. 2. Entitlement to service connection for sleep apnea is remanded. During his June 2016 VA sleep apnea examination, the Veteran reported a history of snoring, daytime hypersomnolence, [and] difficulty breathing during sleep." A sleep study performed in 2014 showed obstructive sleep apnea. The examiner opined that such was less likely related to service since the Veteran's claim folder and VA electronic record were silent for complaints, diagnosis, or therapy of sleep apnea during active duty service. During his October 2019 VA sleep apnea examination, the Veteran stated he underwent a sleep study in 2014 because of his snoring and daytime fatigue, and that he was subsequently diagnosed with obstructive sleep apnea. The examiner opined that the Veteran's sleep apnea was less likely caused by military service since there was no evidence of "sleep apnea, sleep-related breathing disorder, or hypersomnolence occurring during or immediately following military service[.]" Additionally, the Veteran's service treatment records (STRs) were silent for any complaints of sleep issues, and sleep apnea was diagnosed 42 years following his separation from active duty service. During his June 2021 VA sleep apnea examination (conducted via telephone interview), the Veteran reported a history of daytime somnolence, episodes of breathing cessation that wake him up, and loud snoring. The examiner opined that the Veteran's obstructive sleep apnea was likely proximately due to or the result of his service-connected hypertension since, by definition, the two are different disease entities with different pathophysiological processes unrelated to each other. She further opined that the Veteran's obstructive sleep apnea was not aggravated beyond its natural progression by his service-connected hypertension since there was no evidence of hospitalization or surgeries. The Board finds these examinations inadequate as well as they do not adequately address causation and aggravation with respect to the Veteran's service-connected hypertension. Accordingly, a new examination is warranted. The matters are REMANDED for the following action: 1. Obtain copies of VA treatment records from January 2022 to the present. Additionally, all records stored in VistA Imaging must be made available for inclusion in the Veteran's claim file. 2. Obtain, if possible, records of relevant private evaluations and treatment the Veteran has received. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified. 3. After the development in #1 and 2 are complete, arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause of any eye disability diagnosed during the appeal period. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a) Identify, by diagnosis, any eye disability diagnosed during the appeal period. (b) For each disability diagnosed, is at least as likely as not that such was either incurred in or otherwise related to the Veteran's military service, to include exposure to herbicides during active service? (c) If the answer to (b) is no, then for each eye disability diagnosed, is it at least as likely as not (50% or greater probability) that such was either caused OR aggravated by any of the Veteran's service-connected disabilities? Please explain why. The opinion must address both causation AND aggravation, and must specifically address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). The examiner should address whether it is at least as likely as not (50 percent or higher degree of probability) that the Veteran's bilateral ocular hypertension was caused OR aggravated by his service-connected hypertension. 4. After the development in #1 and 2 are complete, arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause his sleep apnea. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a) Is it at least as likely as not that the Veteran's sleep apnea was either incurred in or otherwise related to his military service? (b) If no, the is it at least as likely as not (50% or greater probability) that the Veteran's sleep apnea was either caused OR aggravated by his service-connected hypertension? Please explain why. The opinion must address both causation AND aggravation, and must specifically address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). 5. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Matta, 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.