Citation Nr: 25003333 Decision Date: 03/10/25 Archive Date: 03/10/25 DOCKET NO. 17-61 509 DATE: March 10, 2025 ORDER Service connection for a cervical spine disorder is denied. Service connection for lumbar spine disorder is denied. Service connection for the left shoulder disorder is denied. Service connection for the right shoulder disorder is denied. Service connection for a right elbow disorder is denied. REMANDED Entitlement to service connection for a connective tissue disorder is remanded. Entitlement to service connection for hiatal hernia with reflux is remanded. Entitlement to service connection for a disorder of the left eye is remanded. FINDINGS OF FACT 1. A cervical spine disorder was not shown in service. Degenerative arthritis was not shown to a compensable degree within one year of service, and the symptoms have not been continuous since service; a current cervical spine disorder, diagnosed as degenerative arthritis and degenerative disc disease with intervertebral disc syndrome (IVDS), is not causally or etiologically related to service. 2. A lumbar spine disorder was not shown in service. Degenerative arthritis was not shown to a compensable degree within one year of service, and the symptoms have not been continuous since service; a current lumbar spine disorder, diagnosed as degenerative arthritis and degenerative disc disease, is not causally or etiologically related to service. 3. A left shoulder disorder was not shown in service or to a compensable degree within one year of service, symptoms have not been continuous since service; a current left shoulder disorder, diagnosed as degenerative arthritis, is not causally or etiologically related to service. 4. A right shoulder disorder was not shown in service or to a compensable degree within one year of service, symptoms have not been continuous since service; a current right shoulder disorder, diagnosed as degenerative arthritis with a history of rotator cuff tear, is not causally or etiologically related to service. 5. A right elbow disorder was not shown in service. A current right elbow disorder, diagnosed as lateral epicondylitis, is not causally or etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder, diagnosed as degenerative arthritis and degenerative disc disease with IVDS, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 2. The criteria for service connection for a lumbar spine disorder, diagnosed as degenerative arthritis and degenerative disc disease, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 3. The criteria for service connection for a left shoulder disorder, diagnosed as degenerative arthritis, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 4. The criteria for service connection for a right shoulder disorder, diagnosed as degenerative arthritis, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for a right elbow disorder, diagnosed as lateral epicondylitis, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1965 to February 1969, to include service in the Republic of Vietnam from April 1967 to April 1968. The matters are on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) under the legacy system of appeals. In May 2017, the Veteran testified at a Decision Review Officer (DRO) hearing at the RO. A transcript of this hearing is of record. On his November 2017 VA Form 9, he requested a Board of Veterans' Appeals (Board) hearing. In a November 2021 statement, the Veteran, through his representative, withdrew the Veteran's hearing request. The appeal was previously before the Board in February 2022 and July 2023 at which time the issues were remanded for additional development. In July 2023, the Board directed the agency of original jurisdiction (AOJ) to obtain outstanding service treatment records (STRs) and an additional opinion as to the etiology of the right shoulder disorder. These actions were completed by the AOJ, and the appeal has been returned to the Board for appellate review. Service Connection Initially, for the cervical spine disorder, lumbar spine disorder, left shoulder disorder, right shoulder disorder, and right elbow disorder, a remand is not needed for an opinion regarding toxic exposure risk activity (TERA) as discussed in the remand below. The record reflects that these disorders are associated with physical injury and/or an etiology not related to toxic exposure, which are exceptions to the TERA examination requirement. Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may also be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection for a cervical spine disorder is denied. Regarding the first element of service connection, the evidence establishes a current diagnosis of a cervical spine disability. Specifically, a July 2022 VA examiner diagnosed degenerative arthritis and degenerative disc disease since 2014, as well as a current diagnosis of IVDS. Therefore, the criterion of a current diagnosis is met. As to in-service incurrence, the Veteran's STRs are negative for complaint of, treatment for, and diagnosis of cervical spine disorder. Nevertheless, the Veteran has associated his cervical spine symptoms and diagnosis with the motor vehicle accident (MVA) documented in STRs dated in August 1968. While no cervical spine injury or symptoms were documented at the time, he is competent to describe his symptoms and medical history as he perceived them. Therefore, the criterion of an in-service incurrence is also met. However, a medical nexus is not established. A July 2022 VA examiner opined that the Veteran's cervical spine disorder was less likely than not a result of his military service. The examiner discussed in detail the injuries sustained by the Veteran in the August 1968 MVA and observed that no treatment or diagnosis of the cervical spine were noted in connection with the MVA or at any time during service. The examiner further noted that the veteran had worked as a painter for the USPS for 30 years, which required repetitive motion and was physically demanding. A nexus to military service has not been established. The examiner concluded that cervical degenerative disc disease and arthritis was less likely than not incurred in or caused by the claimed in-service injury, or MVA in August 1968. There are no contradictory competent opinions of record. Accordingly, the weight of the competent and probative evidence is against a nexus to service for a cervical spine disorder on a direct basis. There is no other VA or private medical opinion that alleged any etiological connection between service and the Veteran's current disability. As such, the medical evidence weighs against finding a nexus and does not support service connection on a direct basis. Arthritis is a chronic disease under 38 C.F.R. 3.309 and presumptive service connection will be considered. However, no chronic disease or injury was shown in service. As noted above, the STRs are silent for complaints of, treatment for, or a diagnosis of a cervical spine disorder. Therefore, the medical evidence does not support presumptive service connection on a "chronic disease or injury shown in service" basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the medical evidence shows the earliest date associated with neck pain was 1998, which was noted in a July 2022 headache examination in which the Veteran complained of headaches associated with neck pain in 1998. Further, in the July 2022 VA examination, he reported onset of neck pain in 2000, which he associated with his work as a painter for the USPS. These records are particularly probative as they were given for the purpose of obtaining treatment, incentivizing accuracy. The Veteran separated from service in February 1969. The medical evidence shows that symptoms of his current neck disability developed almost 30 years after service. The onset of symptoms aligns with the July 2022 VA examiner's rationale that his decades of work as a painter with the USPS age was the causative factor for the onset of the Veteran's neck disability. While the Veteran maintains he has neck pain as a result of the August 1968 MVA, this is not supported by the contemporaneous evidence. As such, the medical evidence does not support service connection on a "continuity of symptomatology" basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1969 but did not note symptoms until 1998 at the earliest. Mild degenerative changes in the cervical spine were found on a February 2007 MRI. This evidence does not support presumptive service connection on a "manifest within one-year from separation" basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. The Board has considered the Veteran's lay statements in support of his appeal. Although he believes he has a cervical spine disorder as a result of the August 1968 MVA, in this case he is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of anatomical relationships and the ability to interpret complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The appeal is denied. Service connection for lumbar spine disorder is denied. In a July 2022 VA examination, the examiner noted diagnoses of degenerative arthritis and degenerative disc disease. Therefore, the first element of service connection-a current diagnosis-is met. As to in-service incurrence, the Veteran's STRs are negative for complaint of, treatment for, and diagnosis of a lumbar spine disorder. Nevertheless, the Veteran has associated his lumbar spine symptoms and diagnosis with the August 1968 MVA. While no lumbar spine or other back injury or symptoms were documented at time, he is competent to describe his symptoms and medical history as he perceived them. Therefore, the criterion of an in-service incurrence is also met. However, the criterion of a medical nexus is not met. In the July 2022 VA examination, the examiner documented review of the STRs, including the August 1968 MVA. The examiner observed that the MVA did not involve the lumbar spine and that the claims file was silent for any treatment or management of lumbosacral spine injury or disorder during military service. The examiner noted that the Veteran had worked as a painter with the USPS for nearly 30 years, work which required repetitive motions and physical exertion. The examiner concluded that a nexus to military service was not established and that the Veteran's multi-level disc degeneration and osteoarthritis was less likely than not incurred in or caused by in-service injury, including the MVA. Review of the record does not reveal any competent opinion favorable to a medical nexus. Accordingly, the weight of the competent and probative evidence is against a nexus to service for a lumbar spine disorder on a direct basis. Arthritis is a chronic disease under 38 C.F.R. 3.309 and presumptive service connection will be considered. However, no chronic disease or injury was shown in service. As noted above, the STRs are silent for complaints of, treatment for, or a diagnosis of a lumbar spine disorder. Therefore, the medical evidence does not support presumptive service connection on a "chronic disease or injury shown in service" basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. In the July 2022 VA examination, the Veteran asserted that he had had low back pain since a year after the MVA. However, the evidence does not reflect that these symptoms were indicative of chronic disorder of arthritis. The earliest date associated with a diagnosis of arthritis was 2001 documented by the VA examiner. The Veteran separated from service in February 1969. The medical evidence shows that his current lumbar spine disability developed almost 30 years after service. The onset of symptoms is consistent with the July 2022 VA examiner's rationale that the physical demands of his decades of work as a painter with the USPS was the causative factor for the Veteran's lumbar spine disability. While the Veteran maintains he has a lumbar spine disorder as a result of the August 1968 MVA, this is not supported by the contemporaneous evidence. As such, the medical evidence does not support service connection on a "continuity of symptomatology" basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1969, and in July 2022, he reported that lumbar spine pain first manifested a year after the MVA, i.e., August 1969. However, the medical and lay evidence does not otherwise show that his arthritis was present within a year following discharge in February 1969. Moreover, in a February 1971 letter from a private physician, the clinician summarized the Veteran's medical history and current symptoms as relevant to the MVA, including newly reported symptoms involving the right shoulder, but no complaints concerning the lumbar spine were documented. Further, the clinician noted the spine was "good." Thus, the evidence overall does not support presumptive service connection on a "manifest within one-year from separation" basis. Presumptive service connection for a lumbar spine disorder on any basis is not supported by the medical evidence. The Board has considered the Veteran's lay statements in support of his appeal. Although he believes he has a lumbar spine disorder as a result of the August 1968 MVA, in this case he is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of anatomical relationships and the ability to interpret complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. The appeal is denied. Service connection for the left shoulder disorder is denied. Regarding the first element of service connection, the evidence establishes a current diagnosis of left shoulder disability. In the July 2022 VA examination, the examiner diagnosed degenerative arthritis of the left shoulder. Therefore, the criterion of a current diagnosis is met. As to in-service incurrence, the Veteran's STRs are negative for complaint of, treatment for, and diagnosis of left shoulder disorder. Nevertheless, the Veteran has associated his left shoulder symptoms and diagnosis with the MVA that occurred in August 1968. While no injury to the left shoulder or symptoms in the joint were documented at time, he is competent to describe his perceived symptoms and medical history. Therefore, the criterion of an in-service incurrence is also met. However, the criterion of a medical nexus is not established. The July 2022 VA examiner reviewed the record, including the details of the August 1968 MVA, and summarized the relevant medical history. The examiner noted that the claims file was silent for any treatment or management of a shoulder injury or complaints relevant to the left shoulder during military service and that the MVA did not involve the left shoulder. In addition, the examiner observed that the Veteran had a vocation as a painter for the USPS for 30 years, which was physically demanding work that required repetitive motion. For these reasons, the examiner concluded that a nexus to military service was not established, and the left shoulder degenerative joint disease was less likely than not incurred in or caused by the claimed in-service events or injuries. There are no contradictory competent opinions of record. Accordingly, the weight of the competent and probative evidence is against a nexus to service for a left shoulder disorder on a direct basis. As arthritis has been diagnosed, presumptive service connection will be considered in accordance with 38 C.F.R. 3.309. However, no chronic disease or injury was shown in service. As noted above, the STRs are silent for complaints of, treatment for, or a diagnosis of a left shoulder disorder. Therefore, the medical evidence does not support presumptive service connection on a "chronic disease or injury shown in service" basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the medical evidence shows the earliest date associated with left shoulder pain was 1972, which was noted in a July 2022 VA shoulder examination in which the Veteran associated the left shoulder symptoms with the MVA in August 1968. However, in a June 2002 VA treatment note, he complained of pain in his right shoulder but had zero complaints regarding his left shoulder. This record is particularly probative as they were given for the purpose of obtaining treatment, incentivizing accuracy. The Veteran separated from service in February 1969. The medical evidence shows that symptoms of his current left shoulder arthritis developed over 35 years after service. The onset of symptoms is consistent with the July 2022 VA examiner's rationale that his decades of work as a painter with the USPS age was the causative factor for the onset of the Veteran's left shoulder disability. While the Veteran maintains he has a left shoulder disorder as a result of the August 1968 MVA, this is not supported by the contemporaneous evidence. As such, the medical evidence does not support service connection on a "continuity of symptomatology" basis. Further, the disorder did not manifest to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1969 but identified 1972 as the earliest date of left shoulder symptoms. Degenerative arthritis in the left shoulder was first noted in 2008. This evidence does not support presumptive service connection on a "manifest within one-year from separation" basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. The Board has considered the Veteran's lay statements in support of his appeal. Although he believes his left shoulder disorder is a result of the August 1968 MVA, in this case he is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of anatomical relationships and the ability to interpret complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. The appeal is denied. Service connection for the right shoulder disorder is denied. Regarding the first element of service connection, the evidence establishes a current diagnosis of right shoulder disability. In the July 2022 VA examination, the examiner diagnosed degenerative arthritis of the right shoulder with a history of rotator cuff tear in 1998. Therefore, the criterion of a current diagnosis is met. As to in-service incurrence, the Veteran's STRs are silent for complaint of, treatment for, and diagnosis of right shoulder disorder. Nevertheless, the Veteran has associated his right shoulder symptoms and diagnosis with the MVA documented in in August 1968 STRs. He is competent to describe his symptoms and medical history as he perceived them. Therefore, while no injury to, or symptoms of, the right shoulder were documented at time, the criterion of an in-service incurrence is also met. Regarding a medical nexus, as discussed above, the July 2022 VA examiner opined that a nexus to military service had not been established for degenerative arthritis of the shoulders and the disability was less likely than not incurred in or caused by the claimed in-service events or injuries. However, the Board found the opinion inadequate with respect to the right shoulder and remanded the issue for another opinion in July 2023. The Board noted that the July 2022 VA examiner had not considered 1971 complaints of right shoulder pain since the MVA. The requisite opinion was received in May 2024. The May 2024 VA examiner opined that the Veteran's current chronic right shoulder disorder was less likely than not due to service. The examiner indicated that without chronicity during service or after service, a post-service event, illness, or injury was considered to be a more likely etiology of the disorder. The examiner considered the Veteran's report of right shoulder pain in 1971, as well as his statements and hearing testimony asserting that the disorder was related to the August 1968 MVA. Nevertheless, the examiner found that the record, including post-service medical records and STRs lacked sufficient evidence in support of a chronic right shoulder disorder being caused directly by service, including the MVA. The examiner noted that the STRs were silent for complaint or treatment of a chronic right shoulder disorder, while post-service treatment evidence showed a rotator cuff injury 1998 and degenerative arthritis in the 2000s with a negative X-ray of right shoulder in 2005. The examiner found that the 1998 rotator cuff tear and later degenerative arthritis were not congruent with an injury in the service. There are no contradictory competent opinions of record. Accordingly, the weight of the competent and probative evidence is against a nexus to service for a cervical spine disorder on a direct basis. As arthritis is a chronic disease under 38 C.F.R. 3.309, presumptive service connection will be addressed. However, no chronic disease or injury was shown in service. As noted above, the STRs are silent for complaints of, treatment for, or a diagnosis of a right shoulder disorder. Therefore, the medical evidence does not support presumptive service connection on a "chronic disease or injury shown in service" basis. Next, the medical evidence does not support presumptive service connection based on continuity of symptomatology since service. In 1971, the Veteran reported complaints of right shoulder pain since the August 1968 MVA, and in December 2002, he described a long history of injury dating back to 1969. However, the evidence does not reflect that his symptoms were indicative of a chronic disorder of arthritis. In June 2002, right shoulder symptoms were diagnosed as myalgia, and in December 2002, it was noted that the Veteran had had problems with his right rotator cuff for at least four years with no mention of arthritis. Further, a 2005 X-ray of the right shoulder was negative. Finally, treatment notes dated in July 2006 document the Veteran reporting pain in the right shoulder for 20 years, or since 1986, which would support the connection between his right shoulder disorder and his work as a painter with the USPS discussed by the VA examiner. The Veteran separated from service in February 1969. The medical evidence shows that his current right shoulder arthritis developed more than 35 years after service. The onset of symptoms is consistent with the July 2022 VA examiner's rationale that the physical demands of his decades of work as a painter with the USPS was the cause of the Veteran's right shoulder disorder, as well as the May 2024 VA examiner's rationale that a post-service event, illness, or injury was considered to be a more likely etiology of the Veteran's present right shoulder disability. While the Veteran maintains he has a right shoulder disorder as a result of the August 1968 MVA, this contention is not supported by the contemporaneous evidence. As such, the medical evidence does not support service connection on a "continuity of symptomatology" basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1969, and the first post-service report of right shoulder pain was in February 1971. Moreover, the medical and lay evidence does not otherwise show that his right shoulder arthritis was present within a year following discharge in February 1969. Thus, the evidence overall does not support presumptive service connection on a "manifest within one-year from separation" basis. Therefore, presumptive service connection for a right shoulder disorder on any basis is not supported by the medical evidence. The Board has considered the Veteran's lay statements in support of his appeal. He asserts he has a right shoulder disorder as a result of the August 1968 MVA, in this case he is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of anatomical relationships and the ability to interpret complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. The appeal is denied. Service connection for a right elbow disorder is denied. Regarding the first element of service connection, the evidence establishes a current diagnosis of a right elbow disorder. July 2022 X-rays were negative, and range of motion was normal. However, a July 2022 VA examination noted a diagnosis of lateral epicondylitis. Therefore, the criterion of a current diagnosis is met. As to in-service incurrence, the Veteran's STRs are negative for complaint of, treatment for, and diagnosis of a right elbow disorder. Nevertheless, the Veteran has associated his right elbow symptoms and diagnosis with the August 1968 MVA. While no right elbow disorder or symptoms were documented at the time, he is competent to describe his symptoms and medical history as he perceived them. Therefore, the criterion of an in-service incurrence is also met. However, the criterion of a medical nexus is not met. The July 2022 VA examiner opined that the right elbow disorder was not a result of military service, including the August 1968 MVA. The examiner noted that the MVA did not affect the right elbow. In addition, the examiner observed that post-service the Veteran worked for the USPS for 30 years as a painter, a position that required repetitive motion and was physically demanding. In support of his rationale, the examiner noted a July 2006 VA evaluation of the connective tissue disorder, which yielded a note stating "[complaints of] R elbow and R shoulder pain also assoc[iated] with his painting job. However, [he] has had pain in these areas since an MVA years ago." The examiner further emphasized that X-rays of the right elbow were negative in 2001. The examiner concluded that a nexus to military service, including the MVA in August 1968, had not been established. There are no contradictory competent opinions of record. Accordingly, the weight of the competent and probative evidence is against a nexus to service for a right elbow disorder on a direct basis. The Board considered the Veteran's lay statements in support of his appeal. He associated his right elbow disorder with the August 1968 MVA, but in this case he is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of anatomical relationships and the ability to interpret complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. The appeal is denied. REASONS FOR REMAND Remand is required to obtain medical examinations and/or opinions pursuant to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act). See 38 U.S.C. § 1168. The PACT Act requires that, when his or her active service subjected the Veteran to participation in a toxic exposure risk activity (TERA) and there is evidence of the claimed disability, VA must provide the veteran with a VA examination and obtain a medical opinion addressing the possibility of a nexus between the claimed disability and the TERA. See 38 U.S.C. § 1168 (a)(1). VA's Adjudication Procedures Manual (M21-1), as well as associated reference materials, provides guidance in the development of claims under the PACT act. The record reflects that the Veteran served in the Republic of Vietnam from April 1967 to April 1968, and he is therefore presumed to have been exposed to an herbicide agent. Autoimmune disorders, such as connective tissue disease and Sjogren's syndrome, and gastrointestinal disorders have been determined by the Secretary of VA to not be associated with herbicide exposure. However, the record does not show that a full TERA analysis was performed and documented in a TERA memorandum. This analysis is needed to determine whether a TERA opinion is warranted for these disabilities. M21-1, Part VII, Subpart i, Chapter 1, Section B.1.i. As to the Veteran's left eye disorders, which include glaucoma, pseudophakia, macular degeneration, and posterior vitreous detachment, with a history of cataract surgery, such disorders have not been determined by the Secretary to not be associated with herbicide agents. Therefore, regardless of the findings of a TERA analysis, another opinion as to the etiology of the left eye disorders is needed. The matters are REMANDED for the following actions: 1. Associate with the claims file any outstanding VA treatment notes. 2. Perform a complete TERA analysis for the Veteran and document the analysis in a TERA memorandum. 3. After the above development is completed, obtain an addendum medical opinion from an appropriate clinician(s) regarding the etiology of the Veteran's left eye disorders. The clinician must review the record, including a copy of this remand, and then respond to the following: " Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any of the Veteran's diagnosed left eye disorder(s), which include glaucoma, pseudophakia, macular degeneration, and posterior vitreous detachment, as well as a history of left eye cataract, is related to herbicide agent exposure during service? In providing the requested opinions, the clinician(s) should consider: " the total potential exposure through all applicable deployments; and " the synergistic, combined effect of all toxic exposure risk activities of the Veteran. A complete rationale for any opinion must be provided. If any opinion cannot be provided without a contemporaneous clinical examination, such examination should be scheduled. 4. If warranted by the development under paragraphs (1) and (2) above, obtain opinions as to the etiologies of the Veteran's connective tissue disorder and hiatal hernia with reflux. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. M. Schaefer, 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.