Citation Nr: 22016223 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-26 247 DATE: March 21, 2022 ORDER Service connection for tinnitus is denied. REMANDED Entitlement to service connection for bilateral eye disorders, to include diabetic retinopathy, is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT 1. The Veteran did not serve in the Republic of Vietnam, or in the Korean Demilitarized Zone (DMZ) during the Vietnam era, and the evidence does not establish that he was exposed to Agent Orange during his periods of service. 2. The Veteran's tinnitus was not present during service, or for many years thereafter, and was not caused by any incident of service. CONCLUSION OF LAW The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty the Marine Corps from December 1969 to February 1970. He had additional active duty in the Army from July 1971 to June 1972. The Veteran also had a period of active duty in the Army from July 1972 to May 1973, which was characterized as under conditions other than honorable. This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied service connection for bilateral eye disorders, to include diabetic retinopathy (listed as diabetic retinopathy); bilateral hearing loss; and for tinnitus. In November 2017, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In April 2019 and August 2021, the Board remanded the issues of entitlement to service connection for bilateral eye disorders, to include diabetic retinopathy; bilateral hearing loss; and for tinnitus, for further development. Tinnitus Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). On January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 has added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2), to include parkinsonism, bladder cancer and hypothyroidism. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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."). The Veteran contends that he has tinnitus that is related to service. He specifically maintains that he has tinnitus as a result of exposure to acoustic trauma from loud noise while serving in the Marine Corps, from December 1969 to February 1970, and in the Army, from July 1971 to June 1972. The Veteran reports that he was exposed to noise from weapons, including M16 rifles, 45 caliber pistols, and 50 caliber machine guns, as well as during artillery training as a forward observer. He also reports noise exposure from explosives and grenades. The Veteran further indicates that he was exposed to Agent Orange while serving in Korea during his period of active duty in the Army from July 1971 to June 1972. He states that he was stationed at Camp St. Barbara in Korea, which was eleven miles from the Korean Demilitarized Zone (DMZ), and that he believes he came into contact with Agent Orange while serving as a forward observer in the artillery. The Veteran reports that he was also stationed at Camp Casey and Camp Hovey in Korea. The Veteran indicates that Agent Orange was distributed throughout the Korean DMZ along where Camp Casey and Camp St. Barbara were located, and that he was exposed at that time. The Veteran served on active duty the Marine Corps from December 1969 to February 1970. He had additional active duty in the Army from July 1971 to June 1972. The Veteran also had a period of active duty in the Army from July 1972 to May 1973, which was characterized as under conditions other than honorable. The Veteran's DD Form 214, for his period of active duty in the Marine Corps from December 1969 to February 1970, lists his occupational specialty as a basic marine. His DD Form 214, for his period of active duty in the Army from July 1971 to June 1972, lists his occupational specialty as in light weapons infantry. The Veteran's DD Form 214, for his period of active duty in the Army from July 1972 to May 1973, a period of service characterized as under conditions other than honorable, lists his occupational specialty as a trainee. The Veteran's service personnel records indicate that he served in Korea from December 1971 to June 1972. The Board notes that a Veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides (e.g., Agent Orange) are known to have been applied during that period, shall be presumed to have been exposed during such service to a herbicide agent (e.g., Agent Orange), unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv). The Board observes that the Veteran's service in Korea was after August 31, 1971. Therefore, the Veteran's claimed exposure to Agent Orange is not conceded. The Veteran's service treatment records, for his period of active duty the Marine Corps from December 1969 to February 1970, do not show treatment for tinnitus. His service treatment records for his period of honorable active duty in the Army from July 1971 to June 1972, also do not reflect treatment for tinnitus. Post-service private and VA treatment records, including VA examination reports, show treatment for tinnitus. A December 2013 VA audiological examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he served in the Marine Corps, briefly in the late 1960s, in approximately 1969, but that the did not stay past basic training. He also stated that he served in the Army in the early 1970s. It was noted that the Veteran's DD Form 2014 shows service in 1971 and 1972, with an occupational specialty in light weapons infantry. The Veteran indicated that while serving in the Army, he had excessive noise exposure while training with weapons such as an M16, a 45 caliber pistol, and a 50 caliber machine gun. He maintained that while serving in Korea, for about six months, he had noise exposure from nearby artillery training as a forward observer. He stated that he had a subsequent period of service when he went back in the Army for several months in 1972 or 1973. The Veteran reported, as to occupational noise exposure, that he performed a variety of different work after leaving the military, including flooring work for about twelve years, construction, home remodeling, and driving a truck. The Veteran denied that he had any recreational noise exposure. The Veteran reported that he had low level ringing in his ears for a long time. He stated that he could not recall when the ear noise started, and that he also could not recall if he experienced it while in the military or not. The Veteran indicated that his low level ringing in the ears occurred on and off throughout the day, and that it was more often noticeable in quiet situations, or when he was watching television. He maintained that he had more intense ringing in the ears, intermittently, about once a month, which would last for five minutes at a time. The diagnoses included tinnitus. The examiner indicated that he could not provide a medical opinion regarding the etiology of the Veteran's tinnitus without resorting to speculation. The examiner stated that the Veteran reported a history of weapons noise exposure during training with weapons while serving in the Army as a light weapons infantryman. The examiner indicated that, however, when he asked the Veteran about the onset of his ear noise, he stated that he could not recall when the ear noise started, and that he could not recall if he experienced it while in the military or not. The examiner maintained that the Veteran could only say that he had tinnitus for a long time. The examiner stated that since the Veteran's available service audiograms and physical examinations between July 1971 and November 1972 show normal hearing for both ears, with no evidence of a permanent positive threshold shift greater than normal measurement variability in either ear, there was no evidence of in-service hearing loss to which he could attribute the Veteran's reported tinnitus. It was also noted that there was no documentation of tinnitus complaints or hearing and ear problems. The examiner indicated that the Veteran's inability to recall the onset of his tinnitus during service, his normal hearing documented in the available service physical examination audiograms, and the lack of documentation of tinnitus/ear/hearing complaints in the service treatment records, would not allow him to opine regarding the etiology of the tinnitus to a level of certainty beyond speculation. A March 2020 VA audiological examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he had military noise exposure from explosives, large guns, grenades, and right-handed use of firearms. He denied that he had any post-military noise exposure. The Veteran stated that he had long-term, intermittent, tinnitus. He maintained that he did not know when his tinnitus began, but that he had suffered from it for at least thirty years. The Veteran related that his tinnitus affected his right side and left side, that it occurred weekly, and that it could last for an hour. The diagnoses included tinnitus. The examiner found that the Veteran's tinnitus was less likely than not (less than 50 percent probability) caused by, or a result of, military noise exposure. The examiner reported that there was no significant negative change in hearing between the between a July 1971 enlistment examination and a November 1972 separation examination to indicate that acoustic trauma occurred during service. The examiner stated that, pursuant to the Veteran's report on the length of time he had tinnitus, the tinnitus began well after his military service. The examiner maintained that the Veteran had a clinical diagnosis of hearing loss and that his tinnitus was likely a symptom of the worsening of hearing over time due to age, as well as noise exposure after military service. It was noted that tinnitus was known to be a symptom of hearing loss. A November 2021 VA audiological examination report includes notation that the Veteran's claims file was reviewed. The Veteran reported that his first noticed issues with his hearing after service, not during service. He stated that he could not say with any certainty a year, or even a decade, when his hearing loss began. The Veteran indicated that he was not sure when his tinnitus began. He reported that he did not recall if he had tinnitus during service, and that he could not even narrow it down to a decade. He reported that he was sure that he had tinnitus for at least twenty years. He stated that his tinnitus was constant. The Veteran related that he was exposed to military noise exposure from artillery, rifle fire, and from M60s. He denied that he had any pre-service occupational noise exposure. He indicated that, after service, he had various jobs, including driving a truck, painting houses, and in construction (flooring), with power tools and hand tools. The Veteran denied that he had any recreational noise exposure pre-service, during service, and/or post-service. The diagnoses included tinnitus. The examiner stated that the Veteran had a diagnosis of hearing loss and that his tinnitus was at least as likely as not (50 percent probability or greater) a symptom associated with the hearing loss, as tinnitus was known to be a symptom of hearing loss. The examiner indicated that the Veteran's tinnitus was less likely than not (less than 50 percent probability) caused by, or a result of, his military noise exposure. The examiner reported that the service treatment records show no significant permanent shift in hearing thresholds greater than normal measurement variability, from a December 1969 entrance examination report, to a July 1972 separation examination report, with no evidence of permanent auditory damage on active duty. The examiner stated that there was no complaint of tinnitus in the service treatment records, at separation, or in the medical records until 2013, which was forty years post-service. The examiner indicated that, additionally, the Veteran could not recall when the onset of his tinnitus occurred, and that there was no specific triggering event that was indicated. It was noted that the Veteran did not recall if he had tinnitus during service, and that he could not even narrow his tinnitus down to a decade. The examiner stated that the only information that the Veteran was sure about was that he had tinnitus for at least twenty years. The examiner reported that although noise exposure was conceded as a result of the Veteran's occupational specialty in light weapons infantry, which had a high probability of hazardous noise exposure, and that the relationship between noise, auditory damage, and tinnitus was well documented auditory damage and tinnitus were not conceded based on noise alone. The examiner indicated that there was no evidence and no testimony to support a nexus, or to relate the current hearing loss to military noise/acoustic trauma. The probative value of medical opinion evidence "is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators..." Guerrieri, 4 Vet. App. At 467, 470-71. The determination of credibility is the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens, 7 Vet. App. At 429, 433. The Board notes that there are medical opinions of record that address the etiology of the Veteran's claimed tinnitus, pursuant to a December 2013 VA audiological examination report, March 2020 VA audiological examination report, and a November 2021 VA audiological examination report. A December 2013 VA audiological examination report relates diagnoses, including tinnitus. The examiner, following a review of the claims file, indicated that he could not provide a medical opinion regarding the etiology of the Veteran's tinnitus without resorting to speculation. The examiner stated that the Veteran reported a history of weapons noise exposure during training with weapons while serving in the Army as a light weapons infantryman, but that when he asked him about the onset of his ear noise, he stated that he could not recall when the ear noise started, and that he could not recall if he experienced it while in the military or not. The examiner noted that the Veteran could only say that he had tinnitus for a long time. The examiner stated that since the Veteran's available service audiograms and physical examinations between July 1971 and November 1972 show normal hearing for both ears, with no evidence of a permanent positive threshold shift greater than normal measurement variability in either ear, there was no evidence of in-service hearing loss to which he could attribute the Veteran's tinnitus. It was also noted that there was no documentation of tinnitus complaints or hearing and ear problems. The examiner stated that the Veteran's inability to recall the onset of his tinnitus during service, his normal hearing documented in the available service physical examination audiograms, and the lack of documentation of tinnitus, ear, hearing complaints in the service treatment records, would not allow him to opine regarding the etiology of the tinnitus to a level of certainty beyond speculation. The Board observes that the examiner's opinions are somewhat contradictory. The examiner states that he could not provide a medical opinion regarding the etiology of the Veteran's tinnitus without resorting to speculation, but then, essentially, provides negative etiological opinions by stating that there was no evidence of in-service hearing loss to which he could attribute the Veteran's reported tinnitus, there was no documentation of tinnitus complaints or hearing and ear problems, and that the Veteran had an inability to recall the onset of his tinnitus during service, etc. The Board also notes that at the time of the December 2013 VA audiological report, the Veteran had not been shown to bilateral hearing loss pursuant to 38 C.F.R. § 3.385. Therefore, the Board finds that the examiner's opinions, pursuant to the December 2013 VA audiological examination report, are less probative in this matter. The Board notes that a March 2020 VA audiological examination report relates diagnoses, including tinnitus. The examiner, following a review of the claims file, found that the Veteran's tinnitus was less likely than not probability, caused by, or a result of, military noise exposure. The examiner reported that there was no significant negative change in hearing between the between a July 1971 enlistment examination and a November 1972 separation examination to indicate that acoustic trauma occurred during service. The examiner stated that, pursuant to the Veteran's report on the length of time he had tinnitus, the tinnitus began well after his military service. The examiner maintained that the Veteran had a clinical diagnosis of hearing loss and that his tinnitus was likely a symptom of the worsening of hearing over time due to age, as well as noise exposure after service. The Board observes that the examiner's opinion, as to the etiology of the Veteran's claimed tinnitus, appears to rely, at least in part, on a lack of a significant change in hearing between the between a July 1971 enlistment examination and a November 1972 separation examination to indicate that acoustic trauma occurred during service. Therefore, the examiner appears to indicate that the Veteran did not have acoustic trauma during service. The Board notes, however, that a subsequent November 2021 VA audiological examination specifically indicates that the Veteran had a high probability of hazardous noise exposure. Consequently, the Board finds that the examiner's opinions, pursuant to the March 2020 VA audiological examination report, are less probative in this matter. The Board notes that a November 2021 VA audiological examination report relates diagnoses, including tinnitus. The examiner, following a review of the claims file, indicated that the Veteran's tinnitus was less likely than not caused by, or a result of, his military noise exposure. The examiner reported that the Veteran's service treatment records indicate no significant permanent shift in hearing thresholds greater than normal measurement variability, from a December 1969 entrance examination report, to a July 1972 separation examination report, with no evidence of permanent auditory damage on active duty. The examiner also stated that there was no complaint of tinnitus in the service treatment records, at separation, or in the medical records until 2013, which was forty years post-service. The examiner further indicated that the Veteran could not recall when the onset of his tinnitus occurred, and that there was no specific triggering event that was indicated. It was noted that the Veteran did not recall if he had tinnitus during service, and that he could not even narrow his tinnitus down to a decade. The examiner maintained that the only information that the Veteran was sure about was that he had tinnitus for at least twenty years. The examiner also reported that although noise exposure was conceded as a result of the Veteran's occupational specialty in light weapons infantry, which had a high probability of hazardous noise exposure, and that the relationship between noise, auditory damage, and tinnitus was well documented, auditory damage and tinnitus were not conceded based on noise alone. The examiner indicated that there was no evidence and no testimony to support a nexus, or to relate the current hearing loss to military noise/acoustic trauma. The Board observes that examiner found that the Veteran's tinnitus was less likely than not caused by, or a result of, his military noise exposure. The Board notes that the examiner provided detailed rationales for the stated opinions. Additionally, the Board notes that the examiner specifically discussed the Veteran's occupational specialty in light weapons infantry and noted that such specialty had a high probability of hazardous noise exposure, in providing the opinions. The Board thus finds that the opinions provided by examiner, pursuant to the November 2021 VA audiological examination report, are the most probative in this matter. See Wensch, 15 Vet. App. at 362. The Board observes that the Veteran currently has tinnitus. The Board notes, however, that the medical evidence of record does not suggest that the Veteran's current tinnitus is related to his periods of service. In fact, the medical evidence is against this finding, indicating that his tinnitus began years after his periods of service, without any relationship to any incident of service. The Board notes that there is simply no medical evidence of record relating the Veteran's tinnitus to his period of service. In fact, there are no positive etiological opinions of record. The Veteran appears to allege that his tinnitus may have had its onset during his periods of service, or possibly soon after his periods of service. However, while the Veteran is competent to report ringing in the ears during service, or since service, he is not competent to relate his current tinnitus to service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Buchanan v. Nicholson, 451 F.3d. 1331 (Fed. Cir. 2006) (lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself). In the Veteran's case, such a nexus opinion requires a certain level of expertise given the medically complex question. A lay opinion is not sufficient in this case to prove nexus. Additionally, a VA examiner, in a November 2021 probative opinion, has specifically found that the Veteran's claimed tinnitus was not related to his periods of service. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for tinnitus is warranted. Rather, the evidence persuasively weighs against granting service connection for tinnitus. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. 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). REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for bilateral eye disorders, to include diabetic retinopathy, and for bilateral hearing loss. This case was remanded in August 2021, partly to schedule the Veteran for an appropriate VA examination to determine the onset and/or etiology of his claimed bilateral eye disorders, to include diabetic retinopathy. The examiner was to diagnose all current right eye disorders and left eye disorders, to include diabetic retinopathy (as well as mild nuclear sclerosis of both eyes; mild ocular hypertension of both eyes; evaporative dry eye syndrome; posterior vitreous detachment, both eyes, recent left eye; iritis of the left eye, non-granulomatous; and hyperopic astigmatism of both eyes, etc.) The examiner was to indicate whether it was at least as likely as not that any currently diagnosed right eye disorders and left eye disorders, to include diabetic retinopathy (as well as mild nuclear sclerosis of both eyes; mild ocular hypertension of both eyes; evaporative dry eye syndrome; posterior vitreous detachment, both eyes, recent left eye; iritis of the left eye, non-granulomatous; and hyperopic astigmatism of both eyes, etc.), were related to and/or had their onset during his periods of service. The August 2021 Board remand also directed that the examiner specifically acknowledge and discuss the Veteran's treatment for an abrasion of the right eye during his period of active duty in the Army from July 1971 to June 1972, and any reports by the Veteran of right eye and left eye problems during and since service. The August 2021 Board remand further indicated that the Veteran should be afforded an appropriate VA examination to determine the nature and/or likely etiology of his claimed bilateral hearing loss. If hearing loss was identified, the examiner was to provide an opinion as to whether it was at least as likely as not that any current hearing loss resulted from one or more incidents during the Veteran's periods of service, including his exposure to acoustic trauma. The August 2021 Board remand directed that the examiner must specifically discuss the impact of the Veteran's acoustic trauma on the hair cells in his cochlea, and state whether it was at least as likely as not that any current hearing loss occurred sooner, or progressed to a greater degree of severity than it otherwise would have, as a result of his exposure to acoustic trauma during service. Pursuant to the August 2021 Board remand, the Veteran was afforded a VA eye conditions examination in November 2021. There is notation that the Veteran's claims file was reviewed. The diagnoses were secondary cataracts in both eyes; vitreous degeneration of the right eye; and diabetic retinopathy in both eyes. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that a corneal abrasion was not a risk factor in diabetic retinopathy. The examiner maintained that it was less likely than not ath the claimed condition was caused by the Veteran's in-service injury. The examiner also indicated that the claimed conditions were at least as likely as not (50 percent or greater probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that the Veteran's diabetic retinopathy was directly related to his in-service claimed condition of diabetes mellitus, type 2. The examiner maintained that the diagnoses of nuclear sclerosis (an old diagnosis, as his cataracts were removed), ocular hypertension, and dry eye syndrome could be caused by diabetes mellitus, type 2. The examiner stated that the diagnoses were at least as likely as not caused by the claimed condition. The examiner reported that the Veteran's vitreous detachment was not related to diabetes, and that such diagnosis was not as likely to have been caused by the claimed condition. The examiner maintained that the Veteran's non-granulomatous iritis, which was not active, was less likely to be related to the claimed condition. The examiner further indicated that a hyperopic astigmatism was a normal refractive state and not related to the claimed condition. The Board observes that the examiner indicated that claimed conditions were at least as likely as not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner specifically found that the Veteran's diabetic retinopathy was directly related to his in-service claimed condition of diabetes mellitus, type 2. The examiner maintained that the diagnoses of nuclear sclerosis (an old diagnosis, as his cataracts were removed), ocular hypertension, and dry eye syndrome could be caused by diabetes mellitus, type 2. The examiner stated that the diagnoses were at least as likely as not caused by the claimed condition. The Board notes that the examiner appeared to believe that the Veteran was service-connected for diabetes mellitus, type 2, and then his related his diabetic retinopathy, nuclear sclerosis, ocular hypertension, and dry eye syndrome, to that condition. The Board observes, however, that the Veteran is not service-connected for diabetes mellitus, type 2. In fact, the Board denied service connection for diabetes mellitus in an August 2021 Board decision. Therefore, the Board must find that the examiner's etiological opinions are inadequate. The Veteran was also afforded a VA audiological examination in November 2021, pursuant to the August 2021 Board remand. The diagnoses were sensorineural hearing loss, in the frequency range of 6000 Hertz or higher frequencies in the right ear, and conductive hearing loss, and sensorineural hearing loss, in the frequency range of 6000 Hertz, or higher frequencies, in the left ear. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the claims file shows that all hearing examinations during the Veteran's periods of service, from 1969 to 1973, were within normal limits, with no significant permanent shift in thresholds beyond test variability, which was objective evidence of no permanent auditory damage on active duty. The examiner stated that the claims file is silent from separation until 2013, which was 40 years after service, for any complaints of hearing loss related to service, and a separation examination was within normal limits. It was noted that a VA audiological examination report in 2013 shows hearing thresholds from 500 Hertz to 4000 Hertz, and speech recognition scores, to be within normal limits for VA purposes. The examiner stated that there was a loss noted at 6000 Hertz, at that time, which could possibly be due to acoustic trauma, as hazardous noise can damage hair cells and membranes in the cochlea and exposure to noise can overwork hair cells in the ear, which can cause those cells to die and thresholds to decline generally in the higher frequencies, but that the clinical hearing loss in the 2013 VA examination report did not meet the criteria for a disability per VA standards. The examiner maintained that although noise exposure was conceded given the Veteran's occupational specialty in light weapons infantry, which had a high probability of hazardous noise exposure, and the relationship between noise, auditory damage, and hearing loss, was well documented, auditory damage and hearing loss were not conceded based on noise alone. The examiner indicated that there was no evidence to support a nexus to relate the current bilateral hearing loss to military noise/acoustic trauma. The examiner stated that she did not believe that the Veteran's current hearing loss was outside the typical degree of hearing loss seen with the aging process (presbycusis), especially with the Veteran having a history of diabetes and transient ischemic attacks (small strokes). The Board observes that the examiner's opinions are somewhat contradictory. The examiner indicates that the Veteran's hearing loss at 6000 Hertz, pursuant to a December 2013 VA audiological examination report, could possibly be due to acoustic trauma, as hazardous noise can damage hair cells and membranes in the cochlea and exposure to noise can overwork hair cells in the ear, which can cause those cells to die and thresholds to decline generally in the higher frequencies. The examiner then states that, however, that the clinical hearing loss in the 2013 VA examination report did not meet the criteria for a disability per VA standards. The Board notes that it is unclear, from the examiner's opinions, why a hearing loss at 6000 Hertz in 2013 could be due to acoustic trauma, but the Veteran's subsequent hearing results, which are indicative of right ear and left ear hearing loss, pursuant to 38 C.F.R. § 3.385, would not be due to acoustic trauma. The Board further observes that the examiner did not address whether it was at least as likely as not that any current hearing loss occurred sooner, or progressed to a greater degree of severity than it otherwise would have, as a result of the Veteran's s exposure to acoustic trauma during service, as specifically requested in the August 2021 Board remand. In light of the above, the Board finds that the Veteran should be afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for bilateral eye disorders, to include diabetic retinopathy, and for bilateral hearing loss. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all other medical providers who have treated him for his bilateral eye disorders; to include diabetic retinopathy, and bilateral hearing loss, since June 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed bilateral eye disorders, to include diabetic retinopathy, and bilateral hearing loss. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the onset and/or etiology of his claimed bilateral eye disorders, to include diabetic retinopathy. The entire claims file must be reviewed by the examiner. The examiner must diagnose all current right eye disorders and left eye disorders, to include diabetic retinopathy (as well as mild nuclear sclerosis of both eyes; mild ocular hypertension of both eyes; evaporative dry eye syndrome; posterior vitreous detachment, both eyes, recent left eye; iritis of the left eye, non-granulomatous; and hyperopic astigmatism of both eyes, etc.). The examiner must provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any currently diagnosed right eye disorders and left eye disorders, to include diabetic retinopathy (as well as mild nuclear sclerosis of both eyes; mild ocular hypertension of both eyes; evaporative dry eye syndrome; posterior vitreous detachment, both eyes, recent left eye; iritis of the left eye, non-granulomatous; and hyperopic astigmatism of both eyes, etc.), are related to and/or had their onset during his periods of service. The examiner must specifically acknowledge and discuss the Veteran's treatment for an abrasion of the right eye disorder during his period of active duty in the Army from July 1971 to June 1972, and any reports by the Veteran of right eye and left eye problems during and since service. 4. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the nature and/or likely etiology of his claimed bilateral hearing loss. The entire claims file, to include all electronic files, must be reviewed by the examiner. The examiner must conduct an audiological evaluation, including speech recognition testing, to determine whether the Veteran currently has a hearing loss disability. If hearing loss is identified, the examiner must provide an opinion as to whether it is at least as likely as not that any current hearing loss resulted from one or more incidents during the Veteran's periods of service, including his exposure to acoustic trauma. The examiner must specifically discuss the impact of the Veteran's acoustic trauma on the hair cells in his cochlea, and state whether it is at least as likely as not that any current hearing loss occurred sooner, or progressed to a greater degree of severity than it otherwise would have, as a result of his exposure to acoustic trauma curing service. Additionally, the examiner must specifically acknowledge and discuss any reports by the Veteran that his hearing loss was first manifested during his periods of service and has continued since service. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.