Decision Date: 10/19/95 Archive Date: 10/25/95 DOCKET NO. 94-01 647 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased evaluation for right dacryocystitis, currently evaluated as 10 percent disabling. 2. Entitlement to service connection for post traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. R. Bucci, Associate Counsel INTRODUCTION The veteran served on active duty from November 1959 to June 1966. This appeal arises from an October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. On appeal the veteran has raised the issues of entitlement to the retroactive payment of certain educational/training expenses, and entitlement to a compensable evaluation for pain associated with residuals of a left zygoma and maxilla fracture. These issues, however, are not currently developed or certified for appellate review. Accordingly, they are referred to the RO for appropriate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his right eye disorder is more disabling than is reflected by the currently assigned 10 percent evaluation. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of evidence is against the claim for an increased evaluation for a right eye disorder. FINDINGS OF FACT 1. Right dacryocystitis is productive of impairment no greater than contemplated with only unilateral involvement. 2. The veteran's right dacryocystitis is not shown to markedly interfere with employment, or require frequent periods of hospitalizations. CONCLUSION OF LAW The schedular and extraschedular criteria for an evaluation in excess of 10 percent for right dacryocystitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.84a, Code 6025, 6031 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The service medical records reveal that in May 1962 the veteran was involved in a car accident and as a result developed chronic right dacryocystitis. In September 1963 a dacryocystorhinotomy was performed on the right side. The veteran's June 1966 separation examination was negative for an eye disorder and his bilateral vision was 20/20. A September 1991 VA compensation examination revealed 20/400 bilateral uncorrected vision. The corrected vision was 20/40 in the right eye and 20/30 in the left eye. There was some narrowing of the palpebral fissure on the right compared with the left, however, there was no asymmetry and the lid functioned well. No left eye involvement was noted. The diagnosis was status post reconstruction of right eye tear duct, with resultant narrowing of palpebral fissure. In October 1991, a Rating Board service connected and assigned a 10 percent disability evaluation for right eye dacryocystitis. That rating has since been in effect. At a July 1992 VA visual examination, the veteran was diagnosed with normal vision which was correctable to 20/20. At an October 1993 VA visual examination, the veteran complained of increased mucous in the right eye and intermittent "socket" aches or headaches around the eyes. Examination revealed evidence of a dry eye condition, especially in the right eye and there was a slight superficial punctate staining. The uncorrected visual acuity in the right eye was at near 14/14, and at far 20/100. The bilateral corrected vision was 20/20. The assessment was to change eyeglass prescription for bilateral 20/20 vision. The assessment was that the eye examination was within normal limits except for refractive error, dry eye, increased mucous discharge of the right eye, and complaints of right eye/orbital discomfort/ache. Analysis Initially, the Board notes that the veteran's claim is well- grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on an average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Diagnostic code 6031 provides that dacryocystitis is rated as epiphora. Diagnostic code 6025 provides that unilateral epiphora (interference with the lacrymal duct from any cause) warrants a 10 percent evaluation and bilateral epiphora warrants a 20 percent evaluation. In this case, the clinical evidence does not show that the veteran suffers form bilateral epiphora. Indeed, at the September 1991 VA examination, the diagnosis was status post reconstruction of right eye tear duct, with resultant narrowing of palpebral fissure. At the same examination, no left eye involvement was noted. Moreover, the most current October 1993 VA eye examination was within normal limits except for refractive error, dry eye, increased mucous discharge of the right eye, and complaints of right eye /orbital discomfort /ache. Accordingly, the Board finds the current unilateral symptomatology of the veteran's service connected right dacryocystitis warrants no more than the currently assigned 10 percent evaluation. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.84a, Code 6025, 6031 (1994). In reaching this decision the Board considered the veteran's entitlement to an extraschedular rating. The veteran's right eye dacryocystitis does not, however, present an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment, so as to render impractical the application of regular schedular standards. An extraschedular evaluation is thus not in order. 38 C.F.R. § 3.321(b)(1). While the Board considered the doctrine of affording the veteran the benefit of any existing doubt with regard to the issue on appeal, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant resolution of this matter on that basis. 38 U.S.C.A. § 5107(b). ORDER An increased evaluation for right dacryocystitis is denied. REMAND Service connection for post traumatic stress disorder (PTSD) requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). In this case, the veteran contends that he currently suffers from PTSD, in addition to an anxiety disorder. The veteran has reported several inservice stressors. Essentially, the veteran maintains that his psychiatric disorders are the result of his inservice May 1962 car accident in which his buddy died. The veteran also maintains that he experienced combat while serving two tours in Vietnam on the destroyer, USS Mansfield. The veteran reported an incident in Vietnam which involved a threat of attack on his gunboat. Post service the veteran claims ongoing psychiatric difficulties, as well as problems maintaining relationships and jobs. The record, however, does not contain any post service treatment records prior to April 1991. A review of the available record does indicate that in 1991, the veteran was diagnosed with PTSD by a VA licensed social worker. At a September 1991 VA psychiatric examination, however, the diagnosis was chronic mild to moderate generalized anxiety disorder; chronic mild to moderate dysthymic disorder; and mixed personality disorder. In light of the diagnostic conflict, and the absence of any opinion whether a psychiatric disorder other than PTSD is related to his service, we find that further development is warranted. Finally, the Board acknowledges that the inservice car accident was confirmed by the service medical records and that the RO attempted to obtain all the specifics from the veteran pertaining to his alleged combat related stressors. The record, however, does not indicate that the RO has attempted to verify the veteran's claimed combat stressors through the offices of the U.S. Army and Joint Services Environmental Support Group (ESG). The United States Court of Veterans Appeals in West v. Brown, 7 Vet.App. 70 (1994), held that PTSD claims based on an allegation of a combat stressor require a determination whether or not the veteran actually engaged in combat. Accordingly, as the provisions of the VA ADJUDICATION PROCEDURE MANUAL M21-1 (MANUAL M21-1) pertaining to the adjudication of PTSD provide that, "where records available to the rating board do not provide objective or supportive evidence of the alleged inservice traumatic stressor, it is necessary to develop this evidence." Manual M21-1, Part VI, 7.46(f)(2) (emphasis added). The Board also points out that the veteran's representative, Disabled American Veterans, has also specifically requested that this case be remanded for the above proper development. Accordingly, this case is REMANDED for the following action: 1. The RO should ask the veteran to provide the names and addresses of all medical care providers, private and/or VA, inpatient or outpatient, who have provided treatment since June 1966 for any acquired psychiatric disorder, to include PTSD. After securing any necessary releases, the RO should obtain any outstanding records. 2. The veteran should again be asked to provide specific details about the stressful events he claims to have experienced while serving in Vietnam or the territorial waters thereof. (The inservice car accident has already been confirmed by the service medical records). In this regard, the veteran should be asked to provide the precise dates and places of each claimed stressful event, as well as his unit assignment at the time of each claimed stressor. The veteran should further provide the full names and approximate dates of death of any comrades who were killed or injured in Vietnam or its territorial waters. The RO should also request that the veteran provide the full name and address of any comrade who witnessed any alleged trauma. The RO should then attempt to obtain a "buddy" statement from any identified person. The veteran is hereby informed that the United States Court of Veterans Appeals has held that requiring a claimant to provide this information to the VA does not represent an impossible or onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 3. Thereafter, the information provided by the appellant concerning the specific circumstances of the claimed combat stressors, and a copy of the veteran's service records must be sent to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for verification of any combat related stressors claimed by the veteran. 4. Following the receipt of the ESG's report, and the completion of any necessary development, the RO should prepare a report detailing the nature of any stressful event, that has been verified by the ESG. If no stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 5. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a psychiatrist who has not previously seen or treated the veteran. This examination is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorders sub scales, are to be performed. The claims file must be provided to and reviewed by the examiner prior to conducting this examination. In determining whether the veteran has PTSD the examiner is hereby notified that only the verified history detailed in the reports provided by the ESG and/or the RO may be relied upon. If the examiner believes that PTSD is the appropriate diagnosis the examiner must specifically identify which stressor detailed in the ESG's and/or the RO's report is responsible for that conclusion. If the examiner diagnoses any other acquired psychiatric disorder, to include an anxiety disorder, the examiner is asked to opine whether it is as least as likely as not that the diagnosed disorder, to include an anxiety disorder, is related to the inservice car accident and/or the veteran's active duty service. All opinions expressed must be accompanied by a complete rationale. 6. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD, was based on the verified history provided by the ESG and/or the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. In this respect the Board observes that the Court has held that a diagnosis of PTSD based on an examination which relies upon an unverified history is inadequate for rating purposes. West, 7 Vet.App. at 77. 7. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefit sought on appeal is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be provided. Thereafter, the case should be returned to the Board, if otherwise in order. By this REMAND, the Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action until he is otherwise notified. DEREK R. BROWN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West Supp. 1995), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board's decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994). - 2 -