Citation Nr: 23045294 Decision Date: 08/15/23 Archive Date: 08/15/23 DOCKET NO. 19-09 129 DATE: August 15, 2023 REMANDED 1. Entitlement to service connection for bilateral eye disability claimed as ,due to contaminated water at Camp Lejeune, is remanded. 2. Entitlement to service connection for headaches, claimed as secondary to non-service-connected bilateral eye disability, is remanded. 3. Entitlement to service connection for a psychiatric disorder, claimed as secondary to non-service-connected bilateral eye disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1974 to October 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran provided testimony before the undersigned Veterans Law Judge (VLJ) in April 2022. The VLJ held the record open for an additional 90 days (until July 18, 2022) to give the Veteran an opportunity to submit additional evidence. In July 2022, the Veteran's attorney requested an additional 30 days from July 2022. As a year has passed since the extension request, the Board will now proceed with the appeal. 1. Entitlement to service connection for bilateral eye disability, claimed as due to contaminated water at Camp Lejeune. The Veteran contends that his eye disability was caused by exposure to contaminated water at Camp Lejeune. The Veteran's military personnel records document that he was stationed at Camp Lejeune from July 1975 to October 1975 as an electrician. The Veteran and his attorney argued that a VA examination is warranted to opine as to the etiology of his bilateral eye disability. In a February 2017 statement and at the April 2022 Board hearing, the Veteran indicated that during his training at Camp Lejeune, he was exposed to many chemicals that he ingested through food and drinking water while living on base. He also wrote that he was exposed to other chemical solvent and cleaning supplies and stated he was not provided with protective masks and gloves. While performing his duties as an electrician on hundreds of gasoline and diesel generators, he reported he inhaled fumes and absorbed chemicals. He reported he went to sick bay a few times complaining of nausea, blurred vision, and not feeling well. He wrote that he was given medication, and the symptoms subsided. The Veteran stated after being released from active duty to a reserve unit at Willow Grove, some symptoms returned, and he continued to be exposed to chemicals. He explained that during 1979, he started to lose some of his night vision and was prescribed glasses for distance and night driving. He wrote that in 1981, he started to notice a flashing in his right eye that would not subside. He reported he went to Soil Eye Institute and Wills Eye Hospital and was told it was a retinal detachment and also that he had a strange disease in his right eye as well. He reported the detached retina was repaired at Wills Eye Hospital, but the disease continued. He stated he was told he had an autoimmune disease, and, in 1982, the disease progressed to his left eye causing large amounts of scar tissue that made him totally night blind, and he was not able to drive at night since 1982. He reported that he informed his doctor of PCE TCE chemicals exposure and that Dr. Robert Nusenblatt at NEI, the head of the clinical immunology department, said that they never entertained the idea that this could have caused his problems, but it was definitely a possibility. The Veteran reported Dr. Nusenblatt died in 2016, so he would not be able to testify in the appeal. While the Veteran's bilateral eye disability is not presumptively linked to exposure to contaminated water at Camp Lejeune, the Veteran can still establish service connection on a direct basis. 38 U.S.C.§ 1113(b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a veteran from establishing service connection with proof of actual direct causation). The Veteran submitted a March 2015 medical article entitled, "Committee on the Review of Clinical Guidance for the Care of Health Conditions Identified by the Camp Lejeune Legislation Board on the Health of Select Populations Institute of Medicine Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation Washington (DC) National Academies Press (US)," to support his assertion that his bilateral eye disability is related to exposure to contaminated water at Camp Lejeune. In service connection claims, VA must provide a VA examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability (or persistent or recurrent symptoms of a disability) may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 79 (2006). The requirement that a disability may be associated with service is a "low threshold" standard. Id. at 83. The records document the Veteran was diagnosed with bizarre uveitis with unknown cause, and diffuse irregular scarring, which is from his probable serpiginous chorioretinopathy, disc drusen, and minimal cataract. In light of the article that there may be a correlation between vision changes and exposure to contaminants from Camp Lejeune and considering the low threshold for the McLendon association-to-service element, the Board finds that a VA examination is warranted. To fully address the Veteran's contentions, the medical opinion sought upon remand should also consider the March 2015 article submitted by the Veteran and discuss whether any current bilateral eye disability is directly related to the Veteran's conceded exposure to contaminated water at Camp Lejeune. 2. Entitlement to service connection for headaches, claimed as secondary to non-service-connected bilateral eye disability. 3. Entitlement to service connection for a psychiatric disorder, claimed as secondary to non-service-connected bilateral eye disability. Given that the Veteran claims that his headaches and psychiatric disorder are caused and/or aggravated by his non-service-connected bilateral eye disability and that claim is being remanded, the Board finds remand of the claims for headaches and psychiatric disorder is also warranted, as the issues are intertwined. The matter is REMANDED for the following action: Schedule the Veteran for an in-person examination to determine the nature and cause of his bilateral eye disability. The examiner should have access to and review the claims file. The AOJ must provide a copy of the below facts to the examiner. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record of where this evidence is located: " The Veteran served on active duty from September 1974 to October 1975, to include service at Camp Lejeune from July 1975 to October 1975. Thus, he is presumed to have been exposed to contaminated water while stationed at Camp Lejeune. " The Veteran is claiming that his bilateral eye disability, to include uveitis with unknown cause, a diffuse irregular scarring that is from his probable serpiginous chorioretinopathy, disc drusen, and minimal cataract, was caused by in-service exposure to water contaminants while stationed at Camp Lejeune. " The Veteran's service treatment records are unavailable; however, the January 1974 service entrance Report of Medical Examination and Report of Medical History, do not document the presence of a bilateral eye disability. See VBMS entry with Document Type, "Military Personnel Record," Receipt Date 03/19/2014, with "#4" in the Subject field, pp. 19, 21. " Post-service private treatment records show that in June 1983, the Veteran was diagnosed with "[b]ilateral uveitis, probably atypical acute posterior multifocal placoid pigment epitheliopathy." The examiner noted that a week prior to admission, the Veteran presented with old chorioretinal scar and mild vitreous inflammation in his left eye and a few retinochoroiditis, mainly retinal pigment epithelium (RPE) with mild vitreitis in right eye. The examiner documented the present condition began approximately one year ago with development of scotomas and flashing lights in the one eye. Small retinal hole in left eye was fixed in July 1982 (the record says R eye, but it's clear it is the left eye) and then he developed similar symptoms in R eye. See VBMS entry with Document Type, "Medical treatment Record - Non-Government Facility," Receipt Date 05/20/2014, pp. 6-10. " A Social Security Administration (SSA) record documented the Veteran was awarded SSA disability benefits due to blindness and low vision and the date the disability began was noted as October 2004. See VBMS entry with Document Type, "Medical Treatment Records - Furnished by SSA," Receipt Date 01/11/2017, p. 5. " SSA records show the Veteran reported in a March 2004 letter related to his short-term disability claim that he developed significant change in vision late last summer (summer 2003) that rendered him unable to perform his work duties. See VBMS entry with Document Type, "Medical Treatment Records - Furnished by SSA," Receipt Date 01/11/2017, p. 6. " SSA records include June 2004, August 2004, and March 2005 letters from Dr. Benson, which show collectively he had been the Veteran's eye doctor for 20 years and that he had performed a retinal detachment surgery on the Veteran many years ago. He noted the Veteran suffers from a "bizarre uveitis," which cause is unknown, and that it continues to damage the macula of each eye that makes his sight blotchy and incomplete at best, and that the Veteran had severe loss of visual acuity and peripheral field. See VBMS entry with Document Type, "Medical Treatment Records - Furnished by SSA," Receipt Date 01/11/2017, p. 39-44. " SSA records include an October 2003 letter from Dr. Benson, wherein he documented examination findings, including right eye vision of 20/60 and left eye vision of 20/200. See VBMS entry with Document Type, "Medical Treatment Records - Furnished by SSA," Receipt Date 01/11/2017, p. 48. " An October 2011 letter from Dr. Benson, noted diagnoses of diffuse irregular scarring, which he wrote was from his probable serpiginous chorioretinopathy, disc drusen, and minimal cataract. See VBMS entry with Document Type, "Medical treatment Record - Non-Government Facility," Receipt Date 04/02/2014, p. 8. " In a February 2017 statement, the Veteran stated that during his training at Camp Lejeune, he was exposed to many chemicals that he ingested through food and drinking water while living on base. He also wrote that he was exposed to other chemical solvent and cleaning supplies, and he was not provided with protective masks and gloves. While performing his duties as an electrician on hundreds of gasoline and diesel generators, he reported he inhaled fumes and absorbed chemicals. He reported he went to sick bay a few times complaining of nausea, blurred vision, and not feeling well. He reported he was given medication and the symptoms subsided. He stated that after being released from active duty to a reserve unit at Willow Grove, some symptoms returned, and he continued to be exposed to chemicals. He wrote that during 1979, he started to lose some of his night vision and was prescribed glasses for distance and night driving. He wrote that in 1981, he started to notice a flashing in his right eye that would not subside. He stated he went to Soil Eye Institute and Wills Eye Hospital and was told it was a retinal detachment and a strange disease in his right eye as well. He reported the detached retina was repaired at Wills Eye Hospital, but the disease continued. He reported he was told he had an autoimmune disease in 1982, the disease progressed to his left eye causing large amounts of scar tissue, which made him totally night blind, and he was not able to drive at night since 1982. He reported that he informed his doctor of his exposure to PCE TCE chemicals and that Dr. Robert Nusenblatt at NEI, the head of the clinical immunology department said that they never entertained the idea that this could have caused his problems, but it was definitely a possibility. See VBMS entry with Document Type, "Correspondence," Receipt Date 02/28/2017, pp. 3-5. " The Veteran's wife wrote that the Veteran's eye problems started before their marriage in April 1980. See VBMS entry with Document Type, "Buddy / Lay Statement," Receipt Date 02/28/2017, p. 1. " The Veteran submitted a March 2015 medical article entitled, "Committee on the Review of Clinical Guidance for the Care of Health Conditions Identified by the Camp Lejeune Legislation Board on the Health of Select Populations Institute of Medicine Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation Washington (DC) National Academies Press (US)," to support his assertion that his eye disability is related to exposure to contaminated water at Camp Lejeune. Notably, the authors of the article explained the NRC report found that most human studies indicate effects on visuomotor and motor function fatigue headache and deficits in concentration primarily resulting from acute exposures to solvents. Acute inhalation and oral exposure to PCE can induce symptoms of CNS depression (dizziness and drowsiness) electroencephalographic changes and neuro behavioral changes such as alterations in flash evoked visual potentials. It also noted the 2003 IOM and the 2009 NRC reports found that there was inadequate/insufficient evidence to determine whether an association existed between exposures to solvents and long-term reduction in color discrimination, but noted a study showed the participants in the higher PCE exposure group exhibited lower contrast sensitivity at intermediate and high spatial frequencies than did the unexposed participants although the differences were generally not statistically significant. See VBMS entry with Document Type, "Web / HTML Documents," Receipt Date 01/05/2017. " The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. After a review of the record, including the facts provided above, the examiner should address the following: The examiner should take into account the fact that the Veteran was in Camp LeJeune from July 1975 to October 1975 while in service, where he is presumed to have been exposed to water contaminants, and opine whether the Veteran's bilateral eye disability was caused by or is otherwise related to his active-duty service. The examiner should also consider the March 2015 article submitted by the Veteran and discuss whether any current bilateral eye disability is directly related to the Veteran's conceded exposure to contaminated water at Camp Lejeune. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to the question. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah Campbell, 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.