Citation Nr: 22041006 Decision Date: 07/18/22 Archive Date: 07/18/22 DOCKET NO. 17-28 648 DATE: July 18, 2022 REMANDED Entitlement to service connection for residuals of a left eye injury is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1978 to July 1982. A Board hearing was held before the undersigned Veterans Law Judge in December 2021, and a transcript of the hearing is of record. The Veteran and his representative requested a 30-day continuance to obtain additional evidence in support of the current appeal. More than 30 days have elapsed since the December 2021 Board hearing, and neither the Veteran nor his representative have submitted additional evidence. As the current appeal is being remanded, the Veteran should be afforded another opportunity to submit additional evidence in support of his service connection claim for a left eye condition. The current appeal stems from a June 2012 service connection claim for residuals of a left eye injury. See June 2012 VA Form 21-526; see also December 2021 Board hearing transcript. In reviewing service treatment records, the Veteran was involved in a motor vehicle accident in April 1981 that resulted in a blowout fracture of the left orbit. In an April 1981 ophthalmology consult, the Veteran reported moderate pain and blurred vision in his left eye. In May 1981, the Veteran reported that bright light bothered his left eye. Additionally, the Veteran reported burning, itching, and watering of his left eye. In July 1981, the Veteran underwent surgical repair of his left orbital fracture. See July 1981 Narrative Summary. The provider noted that the Veteran experienced progressive enophthalmos of the left eye following the April 1981 motor vehicle accident. The provider reported that the surgery involved removal of orbital contents from the maxillary sinus, and placement of a silastic implant panel over the orbital wall. The provider indicated that the postoperative course was uncomplicated, but noted that the Veteran had diplopia at extreme upgaze. Following the Veteran's surgical repair of his left orbital fracture, the Veteran reported headaches for two weeks in August 1981, dizziness, and watering of the left eye. The provider noted a superficial scar of the left eye, and non-specific conjunctivitis of the left eye. The Veteran was prescribed eye drops. In a later August 1981 service treatment record, the Veteran reported he was unable to use the prescribed eye drops, and continued to report eye and nose problems. The Veteran requested a skin graft due to the motor vehicle accident, and was advised that the wait list was one or more years. In October 1981, the Veteran reported he felt something in his left eye. The provider observed redness and irritation to the left eye. The provider's assessment was corneal abrasion of the left eye. The Veteran requested revision of keloid scars over his left eye on several occasions in service, with a final request for evaluation in March 1982. However, there does not appear to be an evaluation following the March 1982 request associated with service treatment records. Additionally, the Board observes that a separation medical examination is not associated with service treatment records. In an April 2012 initial visit for VA treatment, the Veteran reported decreased vision in his left eye since the April 1981 motor vehicle accident in service. The Veteran reported that vision in only his left eye was blurry since the motor vehicle accident, and cleared with blinking. In a May 2012 VA eye note, the Veteran reported a pinching pain in his left eye. The provider reported the Veteran had: (1) dry eye syndrome in both eyes; (2) early cataracts in both eyes, mild visual significance right eye versus decreased visual acuity from trauma or dry eye; (3) moderate cupping in both eyes; (4) refractive error/presbyopia. In a February 2013 VA eye note, the provider reported the Veteran's left eye pain could be due to history of trauma or dry eyes. The Veteran's VA treatment records indicate a diagnosis of chronic left eye pain. The Veteran was afforded a VA eye examination in April 2013. The only diagnoses noted by the examiner were the scar on the Veteran's left eyelid, and cataracts. The examiner did not discuss, or appear to consider, the Veteran's additional left eye conditions documented in VA treatment records. In relevant part, the May 2013 rating decision on appeal denied service connection for cataracts of the left eye. During the December 2021 Board hearing, the Veteran testified that he has experienced left eye symptoms continuously since the motor vehicle accident in April 1981, to include pain, tearing of the eye, dry eye, decreased visual acuity, and scarring. Additionally, the Veteran reported that his left eye condition following the April 1981 injury was aggravated by smoke and fumes that he was exposed to as a Quartermaster and Chemical Equipment Repairer. See also DD Form 214. In light of the VA treatment records discussed above and the Veteran's testimony, the Board has expanded the Veteran's service connection claim for a left eye injury to include any residuals of the left eye injury that were incurred in or are otherwise related to service. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (the Board must consider the claimant's description of the claim, symptoms described, and the information submitted or developed in support of the claim). The Board finds that open medical questions remain, and remand is necessary to afford the Veteran a new VA eye examination before an informed decision can be made. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file, to specifically include from the VA medical centers identified by the Veteran during the December 2021 Board hearing. 2. Afford the Veteran an opportunity to submit any additional evidence in support of his current appeal, to include any records of private care. Invite the Veteran to submit release forms to authorize VA to obtain private treatment reports on his behalf. Take all appropriate steps to obtain identified records. 3. Schedule the Veteran for an examination with an examiner who is qualified to address the nature and etiology of the Veteran's claimed left eye condition. The examiner should take a history from the Veteran as to the progression of his claimed left eye condition. Following a review of the claims file, interview and examination of the Veteran, the examiner is asked to respond to the following: (a.) Identify any left eye condition for the period on appeal, to include: ocular pain, left eye; dry eye syndrome; cataracts; cupping; and refractive error/presbyopia. The examiner should consider and discuss the May 2012 VA assessment that appears to suggest the Veteran's diagnosis of early cataracts may be related to trauma. (b.) For each left eye condition identified, is it at least as likely as not (approximately 50 percent or greater probability) that such condition had onset in, or is otherwise related to military service? The examiner should consider the Veteran's report that he experienced left eye symptoms continuously since the motor vehicle accident in April 1981 and July 1981 surgical repair of the left orbital fracture and placement of a silastic implant panel over the orbital wall, to specifically include his report of left eye pain, tearing, dry eye, decreased visual acuity, and scarring. If there is a medical reason to support or call into question the Veteran's reported history as to the progression of his symptoms, this should be made clear. 4. Readjudicate the appeal. If any benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and inform the Veteran of his appeal options. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Mask, Associate 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.