Citation Nr: 22041301 Decision Date: 07/19/22 Archive Date: 07/19/22 DOCKET NO. 18-55 215A DATE: July 19, 2022 REMANDED Service connection for an eye disorder is remanded. Service connection for adjustment disorder, including as due to an eye disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1966 to April 1968. He is the recipient of the Vietnam Service Medal and the Vietnam Campaign Medal. In November 2021, the Veteran testified before the undersigned Veterans' Law Judge. A copy of the transcript is a part of the record. Eye Disorder The Veteran has sought service connection for an eye disorder. He has testified that he had eye surgery prior to service and that the inability to continue with eye therapy during service caused his eye condition to worsen. See November 2021 hearing testimony. In April 2017, the Veteran submitted a private medical report which noted his eye surgery prior to service and recounted the Veteran's report of not being able to continue eye therapy in-service. The private report also noted the Veteran's current diagnosis of a large exotropia with no binocularity. See report submitted in April 2017. The report, however, did not indicate that the Veteran's current eye disorder had any relation to his active duty service, to include his inability continue eye therapy in-service. As such, the private examination report is inadequate to establish service connection. A VA examination conducted in August 2017 also is inadequate as it did not address the Veteran's statement regarding his inability to continue with eye therapy while in-service as well as using an incorrect standard regarding the pre-existing nature of the Veteran's eye disorders. Thus, a new examination is required. Furthermore, it appears that the Veteran has private treatment for his eye disorder; those records are not associated with the claims file. On remand, such records should be made a part of the Veteran's record. Adjustment Disorder The Veteran has sought service connection for his diagnosed adjustment disorder, stating that he thought his condition could be due to both his service in Vietnam and his eye disability. No VA examination regarding the etiology of his diagnosed disorder has been conducted. Remand is necessary as the low threshold for obtaining such an examination has been surpassed in this case. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant private medical treatment records for his eye disorder. After securing the proper authorizations where necessary, arrange to obtain all the records of treatment or examination from all the sources listed by the Veteran that are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making two efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. After any records obtain from Remand directive No. 1, above, have been obtained and associated with the record, schedule the Veteran for a VA medical examination to determine the nature and etiology of any diagnosed eye disorder. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should provide an opinion as to: a. whether there is clear and unmistakable evidence, i.e., evidence for which reasonable medical providers could not differ, that the Veteran had an eye disorder prior to his service; and if so, provide an opinion whether such a disorder was permanently aggravated during his period of active service, to include whether any aggravation or worsening of his condition was caused by an inability to continue with eye therapy; or b. if there is not clear and unmistakable evidence that the Veteran's eye disorder preexisted service, state whether is it at least as likely as not that his eye disorder was incurred in, or due to, the Veteran's service, to include whether his condition was caused by an inability to continue with eye therapy. The examiner must provide a complete rationale on which his/her opinion is based and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Veteran's lay assertions as to onset and continuity of symptomatology, specifically his November 2021 hearing testimony, should be recorded and considered. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his diagnosed adjustment disorder. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner must opine whether: a. it is at least as likely as not that the Veteran's adjustment disorder was incurred in, or due to, the Veteran's service, to include his service in the Republic of Vietnam; or b. or was caused or aggravated by his eye disorder. The Veteran's lay statements regarding onset and continuity of symptomology, specifically his November 2021 hearing testimony, should be recorded and considered. A rationale for all opinions must be provided. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Parrish 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.