Citation Nr: 22017782 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-57 799 DATE: March 26, 2022 ORDER Entitlement to service connection for paralysis of the left third cranial nerve, as secondary to the service-connected Horner's syndrome, is granted. REMANDED Entitlement to an initial compensable rating for status post bilateral dissection of carotid is remanded. Entitlement to an initial disability rating in excess of 10 percent for ptosis of the left eye with anisocoria and Horner's syndrome is remanded. FINDING OF FACT The Veteran's paralysis of the left third cranial nerve is proximately due to his service-connected Horner's syndrome. CONCLUSION OF LAW The criteria for service connection for paralysis of the left third cranial nerve, as secondary to the service-connected Horner's syndrome, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from October 2001 to August 2002, from October 2002 to September 2003, from October 2003 to March 2004, from December 2005 to April 2006, from June 2010 to February 2011, and from February 2012 to February 2014. These issues are on appeal from a June 2015 rating decision and in July 2021, the Veteran testified before the undersigned at a Board of Veterans' Appeals (Board) hearing. While the Veteran had been previously represented by Military Order of the Purple Heart, upon being advised that this service organization was no longer offering representation to Veterans before the Board, the Veteran indicated that at this time, he wished to go forward with his appeal on his own. 1. Entitlement to service connection for paralysis of the left third cranial nerve, as secondary to the service-connected Horner's syndrome. The Veteran has testified that his facial nerve was damaged and caused permanent disfigurement. See Board hearing transcript, page 9. He testified that all of these symptoms could be attributed to his service-connected disability. Id. In a September 2015 Peripheral Nerves Condition Disability Benefits Questionnaire (DBQ), the Veteran's private certified family nurse practitioner diagnosed the Veteran with paralysis of the left third cranial nerve. Similarly, in a September 2015 Eye DBQ, Dr. Holcomb, the Veteran's private eye optometrist, diagnosed the Veteran with a neurologic eye condition specifically, paralysis of the left third cranial nerve. In the September 2015 Peripheral Nerves Condition DBQ, the nurse practitioner noted the Veteran's reports of left-sided facial numbness, mostly in the eye and check area. The nurse practitioner found that the Veteran has Horner's syndrome that interrupts the sympathetic nerve supply to the eye. There are no negative nexus opinions of record. Upon review of the record, the Board therefore finds the evidence supports that the Veteran's current paralysis of the left third cranial nerve is proximately due to his service-connected Horner's syndrome. After resolving all doubt in favor of the Veteran, the Board finds that service connection for paralysis of the left third cranial nerve is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Agency of Original Jurisdiction will assign an initial rating and effective date following the Board's grant of service connection. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for status post bilateral dissection of carotid is remanded. During the Board hearing, the Veteran identified relevant outstanding private treatment records (specifically, Eastern Virginia Medical School). Also, the Veteran submitted a September 2015 DBQ from his treating nurse practitioner at the Atwood Family Medical Center. These private treatment records are not contained in the Veteran's electronic claims file. A remand is required to allow VA to obtain authorization and request these records. 2. Entitlement to an initial disability rating in excess of 10 percent for ptosis of the left eye with anisocoria and Horner's syndrome is remanded. During the Board hearing, the Veteran identified relevant outstanding private treatment records (specifically, Dr. Holcomb, his private optometrist). The Veteran also submitted an August 2021 private medical opinion from the EVMS Medical Group. These private treatment records are not contained in the Veteran's electronic claims file. A remand is required to allow VA to obtain authorization and request these records. The AOJ has previously rated the Veteran's service-connected disability under 38 C.F.R. § 4.79, Diagnostic Codes 6066-6080. However, the Board notes that under Diagnostic Code 6019, ptosis is to be evaluated based on visual impairment or, in the absence of visual impairment, on disfigurement (38 C.F.R. § 4.118, Diagnostic Code 7800, which applies to scars and disfigurement of the head, face, or neck.). Scarring or disfigurement were not documented at the most recent May 2015 VA eye examination. Since that examination, the Veteran testified that his face was disfigured because his left eye drooped and there was a slight drop in the left side of his face. See Board hearing transcript, pages 3, 9. An August 2021 private medical opinion documents that, "This has been disfiguring to him with drooping of the eyelid on his left side." This evidence suggests that the Veteran's left eye disability has increased in severity since he was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his left eye disability. Further, the Veteran has reported symptoms of photophobia, pain, glare sensitivity, anhydrosis, dry eye, and increased eye drooping and eye pressure flare-ups during weather changes in the left eye. See Board hearing and September 2015 Eye DBQ. The Veteran was also diagnosed with left eye cataracts at the May 2015 VA eye examination, and keratitis sicca at the September 2015 Eye DBQ. The Board is requesting a medical opinion upon remand to determine whether these reported symptoms and diagnoses are manifestations of the Veteran's service-connected left eye disability. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for Eastern Virginia Medical School. Make two requests for the authorized records from Eastern Virginia Medical School, unless it is clear after the first request that a second request would be futile. 2. Ask the Veteran to complete a VA Form 21-4142 for Atwood Family Medical Center. Make two requests for the authorized records from Atwood Family Medical Center, unless it is clear after the first request that a second request would be futile. 3. Ask the Veteran to complete a VA Form 21-4142 for Dr. Holcomb. Make two requests for the authorized records from Dr. Holcomb, unless it is clear after the first request that a second request would be futile. 4. Ask the Veteran to complete a VA Form 21-4142 for EVMS Medical Group. Make two requests for the authorized records from EVMS Medical Group, unless it is clear after the first request that a second request would be futile. 5. Schedule the Veteran for an examination by a licensed optometrist or ophthalmologist to determine the current severity of the Veteran's service-connected ptosis of the left eye with anisocoria and Horner's syndrome. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner is asked to provide the following opinions: (a) Is it at least as likely as not that the Veteran's reported symptoms of photophobia, pain, glare sensitivity, anhydrosis, dry eye, and increased eye drooping and eye pressure flare-ups during weather changes in the left eye are proximately due to his service-connected ptosis of the left eye with anisocoria and Horner's syndrome? (b) Is it at least as likely as not that the Veteran's reported symptoms of photophobia, pain, glare sensitivity, anhydrosis, dry eye, and increased eye drooping and eye pressure flare-ups during weather changes in the left eye are aggravated beyond their natural progression by his service-connected ptosis of the left eye with anisocoria and Horner's syndrome? (c) Is it at least as likely as not that the Veteran's currently diagnosed cataracts and/or keratitis sicca in the left eye is proximately due to his service-connected ptosis of the left eye with anisocoria and Horner's syndrome? (d) Is it at least as likely as not that the Veteran's diagnosed cataracts and/or keratitis sicca in the left eye is aggravated beyond its natural progression by his service-connected ptosis of the left eye with anisocoria and Horner's syndrome? The examiner must review the Veteran's claims file and should note that a review was conducted in the examination report. A complete rationale must be provided for all opinions expressed. If it is not possible to provide an opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge, a deficiency in the record and additional facts are required, or the examiner does not have the knowledge or training). If additional diagnostic testing would be helpful, the examiner should identify such testing. 6. Schedule the Veteran for a scars/disfigurement examination by an appropriate clinician to determine the current severity of the Veteran's service-connected ptosis of the left eye with anisocoria and Horner's syndrome. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must specifically address the severity of any disfigurement (including drooping) or scars associated with the Veteran's left eye disability. Color photographs must be taken of the left eye. 7. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran's satisfaction, send the Veteran a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Watkins, 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.