Citation Nr: 25005116 Decision Date: 04/15/25 Archive Date: 04/15/25 DOCKET NO. 16-16 678 DATE: April 15, 2025 REMANDED Entitlement to service connection for a bilateral eye condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1984 to August 1990. He appeals a July 2014 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for "astigmatism with presbyopia also claimed as blurred vision." See July 2024 rating decision. This case has a lengthy procedural history. After two remands by the Board of Veterans' Appeals (Board) in February 2019 and June 2021, the Board denied service connection for a bilateral eye condition in October 2021. See October 2021 Board decision. In December 2022, pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board's October 2021 decision and remanded the issue back to the Board. See December 2022 JMR. Most recently, in September 2024 the Board remanded the issue yet again for further evidentiary development. See September 2024 Board remand. The appeal is now back before the Board. Unfortunately, another remand is required to obtain an adequate medical opinion regarding the nature and etiology of the Veteran's reported eye condition. Pursuant to the September 2024 Board remand, the Veteran was afforded a VA examination in December 2024. However, the Board finds that the resulting VA opinions are inadequate for the following reasons. Preliminarily, the Board notes that the Veteran contends, in part, that his bilateral eye condition is secondary to his service-connected diabetes mellitus (DM) and/or migraines. When the December 2024 VA examiner provided his causation opinions, he concluded that the Veteran's eye condition was not "proximately due to or the result of" his service-connected condition. See December 2024 VA medical opinion (emphasis added). Here, the examiner's reference to "proximate causation" is improper-establishing service connection on a secondary basis does not require a showing of proximate causation, but only but-for causation. See Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023); 38 U.S.C. § 1110. Further, as to the question of aggravation, the December 2024 VA examiner opined that the Veteran's "claimed condition was less likely than not aggravated beyond its natural progression by [his] service connected [sic] condition." See December 2024 VA medical opinion (emphasis added). However, the Board notes that the examiner applied the wrong standard for aggravation of "beyond the natural progression" instead of the correct standard of "any increase" in disability. 38 C.F.R. § 3.310(b); Allen v. Brown,7 Vet. App. 439 (1995). Additionally, the examiner concluded that the Veteran's only eye diagnoses present were myopia and regular astigmatism. He failed to address the other claimed eye disabilities and symptoms listed within the prior September 2024 Board remand, reasoning that "The Report of Medical Examination for separation shows no eye problems other than refractive error. The [V]eteran denies any eye trauma, or treatment for any eye problems during service, and the STR's provide [sic] to me do not show any eye problems while in service." See December 2024 VA examination report. First, the examiner failed to account for the relevant evidence, including the Veteran's competent lay statements regarding his symptoms of constant "noisy vision," which he specifically endorsed upon examination. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that an examination must take into account an accurate history to be adequate). Further, the examiner relied primarily on the absence of contemporaneous medical records when failing to diagnose any eye disabilities outside of myopia and astigmatism; such an opinion is inadequate for adjudicative purposes. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). Based on the foregoing, the Board finds that the December 2024 VA examination and resulting opinions are inadequate for adjudicative purposes and remand is required. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Lastly, the Board notes that there are likely outstanding relevant VA treatment records. Specifically, the Veteran's VA treatment records contain scanned documents into the VistA Imaging system and Computerized Patient Record System (CPRS) that are not associated with the claims file, and the Board does not have access to these systems. For example, there are various community care consult result notes scanned into VistA Imaging within the Veteran's treatment records. See, e.g., April 10, 2024 VA treatment note. Additionally, in a February 2024 endocrinology telephone encounter note, the VA clinician notes "CPRS chart review" in connection with the telephone consultation with the Veteran. See February 14, 2024 VA treatment note. Ultimately, the Veteran's VA treatment records contain a multitude of scans into the VistA Imaging system and CPRS. These scanned documents which are unavailable to the Board may very well be relevant to the instant appeal. On remand, the AOJ shall attempt to obtain and associate any outstanding relevant records viewable in VistA Imaging with the Veteran's claims file. The matters are REMANDED for the following action: 1. Obtain all outstanding and updated relevant VA and/or private treatment records and associate the same with the claims file, to include any outstanding relevant records viewable in VistA Imaging and CPRS. 2. Thereafter, schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of any eye condition, to include myopia, presbyopia, astigmatism, ophthalmoplegia migraine (OM), and the Veteran's reports of blurry vision. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. After a thorough review of the record to include all in-service and post-service treatment records, the examiner should answer the following for each eye condition, to include myopia, presbyopia, astigmatism, OM, and the Veteran's reports of blurry vision: (a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the eye condition, is solely attributable to a congenital disease (meaning the condition can improve or deteriorate) instead of a congenital defect (meaning the condition is static in nature, and cannot generally improve or deteriorate)? (b.) If a congenital disease, the examiner should discuss the condition and state whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the condition was (i) caused OR (ii) aggravated by the Veteran's service-connected DM and/or migraines? (c.) If a congenital defect, does the Veteran have a superimposed disease or injury? If so, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the superimposed disease or injury was (i) caused OR (ii) aggravated by the Veteran's service-connected DM and/or migraines? (d.) If the condition is neither a congenital disease nor congenital defect, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's condition was (i) caused OR (ii) aggravated by his service-connected DM and/or migraines? The examiner should consider the following: (A) August 2008 VA treatment records reflecting the Veteran reported blurry vision and flashes of light in his left eye for four hours without any accompanying pain; (B) September 2014 VA treatment records for an optometry consultation where it was noted the Veteran's contact lenses were accurate and provided clear vision, but today "his vision has been blurry overall" and "he has had a history of fluctuations [in] vision for many years now;" (C) January 2015 Kaiser Permanente records reflecting Dr. R.R. diagnosed the Veteran with "probably ocular migraines on the background of a poorly controlled migraine condition," a neurology appointment was made to review "migraine headache associated with blurry vision" that was "worse in the last six months," and a diagnosis of "ophthalmic migraine." In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran's reports, he or she must provide an explanation for such rejection. 3. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case (SSOC) and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Poe, 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.