Citation Nr: A25041250 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 210922-186601 DATE: May 6, 2025 REMANDED Entitlement to a compensable evaluation for bilateral pinguecula with corneal neovascularization is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1984 to June 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2021 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In the September 22, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the June 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. However, because the Board is remanding the claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). 1. Entitlement to a compensable evaluation for bilateral pinguecula with corneal neovascularization. The Veteran seeks a compensable evaluation for his eye disability. In March 2021, the Veteran wrote that he had "major problems and pain in both eyes." He stated, "they tear most of the time", during cold weather he has difficulty seeing because of the tearing, and at times his eyes burn/sting and turn red. The Veteran submitted to a VA examination in June 2021. The VA examiner noted diagnoses of bilateral corneal neovascularization, bilateral age-related nuclear cataract, and bilateral pinguecula. The examiner noted that the Veteran had vision loss in the left eye, which "was found while measuring visual acuities for this DBQ and comparing them to visual acuities done for a previous DBQ done in 2017 establishing a reduction of visual acuity at both distance and near in the left eye from 20/20 to 20/60." The examiner noted that pinguecula was stable with no current symptoms and no treatment. The Veteran had current symptoms of blurred vision in the left eye. The VA examiner noted the Veteran's report that the eyesight in his left eye has been gradually getting worse for the "past few years." The Veteran's corrected distance visual acuity was 20/20 or better in the right eye and 20/70 in the left eye. There was no anatomical loss, light perception only, extremely poor vision or blindness of either eye, diplopia, or any documented visual field defects. External examination was abnormal, with the examiner finding pinguecula, corneal neovascularization, and age-related nuclear cataract, all bilaterally. Internal eye exam was normal. There were no incapacitating episodes or scarring/disfigurement attributable to the Veteran's bilateral corneal neovascularization. The VA examiner noted the Veteran's decrease in visual acuity or other visual impairment is not attributable to the pinguecula or corneal neovascularization. They further noted that left eye vision loss is of unknown etiology. The examiner remarked that "due to a lack of objective evidence to provide a cause for the Veteran's left eye vision loss, it was not given a diagnosis." The Veteran did not have scarring or disfigurement attributable to any eye condition. The examiner also noted that the Veteran did not have any incapacitating episode attributable to any eye condition during the past 12 months. The examiner opined that corneal neovascularization was a progression of the service-connected pinguecula as it was a result of surgery done to remove pterygium that was caused by the pinguecula. For the diagnosis of bilateral nuclear cataracts, the examiner opined that the veteran's cataracts were of the age-related type not medically associated with any in service event or illness. Regarding the vision loss in the left eye, the examiner noted that had no known etiology to associate with any service-connected event or illness. The Board finds the examination inadequate for rating purposes. While the examiner noted that the Veteran's service connected bilateral eye disabilities were stable and did not have any symptoms, at the time of the examination the record showed increased symptoms of pain, tears, and burning/stinging. The examiner failed to address the Veteran's statements regarding these symptoms. Furthermore, there is no adequate rationale on the Veteran's loss of vision of left eye; the examiner stated that the etiology was "unknown" and could not give a diagnosis due to "lack of objective evidence" but opined that it was not associated "with any service-connected event or illness". In other words, he did not note whether the inability to provide an opinion is due to a lack of personal knowledge, a lack of knowledge in the medical community, or a deficiency in the record. The failure to obtain an adequate examination is a pre-decisional duty to assist error noted. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Remand is warranted for this reason. The Veteran contends that VA did not request his medical records from Williamson Eye Center of Baton Rouge. In his June 2021 statement (received September 2021 with the 10182), the Veteran stated that he had eye surgery at this facility in 2004 or 2005. The November 2017 VA examination states that the Veteran had pterygium surgery at this facility in 2006/2007. The Board finds that these records are not relevant to the current severity of the Veteran's service connected bilateral eye disabilities. Further, the Veteran has stated that these records were lost or destroyed several years ago. See September 2021 Correspondence. Accordingly, there was no pre-decisional duty to assist error in not obtaining these records. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by a clinician who has not previously examined the Veteran to determine the current severity of his service-connected bilateral pinguecula with corneal neovascularization. The examination report must reflect that the claims file was reviewed. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's service connected bilateral eye disabilities under the rating criteria, including detailed analysis of visual field chart(s)/results. (a.) For each and every diagnosed eye disability throughout the period on appeal (November 2019 to present) that is not already service-connected, the examiner must opine if the disability is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused by a service-connected eye disability and/or a combination of service-connected eye disabilities (including treatment). (b.) For each and every diagnosed eye disability throughout the period on appeal that is not already service-connected, the examiner must opine if the disability is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated by (any worsening) a service-connected eye disability and/or a combination of service-connected eye disabilities (including treatment). The examiner must specifically address the left eye vision loss noted in the June 2021 VA eye examination. The examiner must also specifically address the Veteran's symptoms mentioned in his March 10, 2021 Correspondence (i.e., pain, tears, burning/stinging). If they are not associated with the bilateral pinguecula with corneal neovascularization disability, he or she must explain such a conclusion and identify which diagnosis is responsible for the symptoms. A clear rationale must be provided for all opinions expressed. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must note if the inability is due to a lack of personal knowledge (the examiner does not have the knowledge or training); or a lack of knowledge in the medical community (no one could respond given medical science and the known facts); or a deficiency in the record (additional facts are required). Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Romero-Sanchez, Emma J. 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.