Citation NR: 9624588	
Decision Date: 08/28/96		Archive Date: 09/04/96
DOCKET NO.  90-19 104	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, 
Ohio


THE ISSUES

1.  Entitlement to service connection for defective vision as 
secondary to medication taken for service-connected post 
traumatic stress disorder with alcoholism.

2.  Entitlement to an increased evaluation for post traumatic 
stress disorder with alcoholism, currently evaluated as 50 
percent disabling.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Service representative


ATTORNEY FOR THE BOARD

Ronald R. Bosch, Counsel



INTRODUCTION

The veteran served on active duty from August 1965 to August 
1968.

This appeal arose from a May 1989 rating decision of the 
Department of Veterans Affairs (VA) Regional Office (RO) in 
Cleveland, Ohio.  The RO denied entitlement to an increased 
evaluation for post traumatic stress disorder.

The RO denied entitlement to service connection for defective 
vision as secondary to medication taken for service-connected 
post traumatic stress disorder when it issued a rating 
decision in March 1990.

The Board of Veterans’ Appeals (Board) remanded the case to 
the RO for further development in November 1990.

The RO granted entitlement to service connection for 
alcoholism as secondary to service-connected post traumatic 
stress disorder when it issued a rating decision in April 
1991.

The Board remanded the case to the RO for further development 
in March 1992.

The RO, in pertinent part, affirmed the denial of entitlement 
to service connection for defective vision as secondary to 
service-connected post traumatic stress disorder with 
alcoholism in previous rating decisions and when it most 
recently issued a rating decision in November 1995.

The case has been returned to the Board for final appellate 
review.


CONTENTIONS OF APPELLANT ON APPEAL

The veteran contends that his defective vision is secondary 
to medication he has taken over the years for treatment of 
his service-connected post traumatic stress disorder, thereby 
warranting entitlement to a grant of service connection on a 
secondary basis.  The appellant contends that his post 
traumatic stress disorder is far more disabling than 
currently evaluated, thereby warranting entitlement to an 
increased evaluation.


DECISION OF THE BOARD

The Board, in accordance with the provisions of 38 U.S.C.A. 
§ 7104 (West 1991 & Supp. 1995), has reviewed and considered 
all of the evidence and material of record in the veteran's 
claims files.  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 record supports a grant 
of entitlement to service connection for defective vision as 
secondary to medication taken for treatment of post traumatic 
stress disorder.

It is the decision of the Board that the record supports a 
grant of entitlement to a 100 percent evaluation for post 
traumatic stress disorder.


FINDINGS OF FACT

1.  VA examiners have on more than one occasion opined that 
the veteran has defective vision bilaterally as the result of 
Mellaril (Thioridazine) toxicity in connection with treatment 
of his service-connected post traumatic stress disorder.

2.  Post traumatic stress disorder is productive of totally 
disabling psychoneurotic symptomatology and has rendered him 
unable to obtain and retain substantially gainful employment.


CONCLUSIONS OF LAW

1.  Defective vision is proximately due to or the result of 
medication taken for treatment of service-connected post 
traumatic stress disorder.  38 U.S.C.A. § 5107 (West 1991);  
38 C.F.R. § 3.310(a) (1995).

2.  The criteria for a 100 percent evaluation for post 
traumatic stress disorder have been met.  38 U.S.C.A. §§ 
1155, 5107 (West 1991);  38 C.F.R. §§ 3.321(b)(1), 4.7, 
4.132, Diagnostic Code 9411 (1995).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Initially, the Board notes that the veteran has presented 
evidence of well grounded claims within the meaning of 
38 U.S.C.A. § 5107(a), in that he has presented claims which 
are plausible.  The Board is satisfied that as a result of 
the previous remands of the case to the RO for further 
development, all relevant facts have been properly developed, 
and that no further assistance to the veteran is required in 
order to comply with 38 U.S.C.A. § 5107(a).


I.  Entitlement to service connection for 
defective vision as secondary to 
medication taken for treatment of 
service-connected post traumatic stress 
disorder.

Factual Background

No significant vision abnormalities were noted when the 
appellant was examined by VA in July 1969.

The appellant complained of blurred vision when he underwent 
a special psychiatric examination by VA in October 1972.

An April 1973 VA eye examination report shows bilateral 
uncorrected visual acuity was 10/200. 

An August 1976 VA consultation report shows pigmentary 
changes were seen in both macular areas.  The examiner noted 
the diagnosis of the macular changes explained the reduction 
of vision, and that it could be due to Mellaril.  He noted 
the veteran was advised not to use Mellaril.  It could be 
substituted with something that did not have a retina toxic 
effect.

A September 1976 VA consultation report shows a fundus 
examination revealed pigmentary changes in the macular area 
and perimacular area.  The examiner noted the veteran had 
macular involvement of both eyes besides the irreversible 
changes with pigmentary disturbance.  The examiner noted he 
would like the veteran to discontinue all medication like 
Thorazine, Stelazine, and Mellaril group of medicines.  The 
examiner noted if he was already on this type of medicine, it 
should be discontinued before he had worse problems than 
those he had presently.

A June 1977 VA consultation report shows the fundus 
examination revealed macular degenerative changes in both 
eyes, right eye more than the left eye, which can be 
secondary to Thorazine, Stelazine, or Mellaril group of 
medicine.  The examiner noted there was no treatment for it.

A January 1978 VA consultation report shows the veteran had 
macular changes in both eyes and visual acuity was 20/100 in 
each eye.

A December 1978 letter on file from the Chief of the local VA 
Optometry Service noted that veteran’s corrective lenses were 
found to be 10/160 in the right eye and 10/400 in the left 
eye.  He was considered to be legally blind.

An August 1989 VA special eye examination concluded in a 
finding of macular disruption bilaterally secondary to 
Mellaril toxicity.

An April 1991 VA special ophthalmology examination report 
shows the apparent cause of the veteran’s reduced vision was 
the toxic effects of drug therapy, noted as Mellaril and 
Thorazine.

On file are letters dated in March and June 1991 from a 
private peripatologist pertaining to training of the veteran 
for successful adjustment in a daily environment with reduced 
visual acuity.

An April 1992 VA consultation report shows diagnostic 
impressions of Phenothiazine toxicity of the macula 
bilaterally and legal blindness bilaterally secondary to the 
above.

In May 1992 a VA optometrist opined that the veteran had 
severely reduced visual acuity bilaterally secondary to 
Mellaril (Thioridazine) induced retinopathy.

In November 1992 the veteran submitted a medical extract from 
a private manuscript pertaining to the toxic effects of 
Mellaril.  Also on file is another medical extract from a 
different private publication on the same subject.

A service representative testified on the veteran’s behalf in 
support of the claim for service connection for defective 
vision secondary to medication taken for treatment of 
service-connected post traumatic stress disorder at an RO 
hearing held in January 1994.

A January 1994 VA special ophthalmologic examination 
concluded in diagnostic impressions of retinal pigment 
epithelium atrophy of macula bilaterally consistent with 
Thioridazine toxicity; and legally blind secondary to 
Thioridazine toxicity.

In February 1994 a VA ophthalmologist opined that the veteran 
had decreased visual acuity bilaterally secondary to pigment 
epithelial dystrophy consistent with over treatment with 
Thioridazine.

A March 1994 VA special psychiatric examination report shows 
an examiner noted the veteran reported using Mellaril 
beginning in 1973 and continuing such use for 10 years.  The 
examiner referred to a report dated in March and April 1976 
showing the veteran had been prescribed Mellaril, but there 
was no documentation to indicate that he received any dosages 
of this medication greater than 600 milligrams per day.  This 
was in contrast to the report wherein he stated he was 
receiving upwards of 1,400 milligrams per day.  In August he 
was advised to discontinue this medication.  This was in 
contrast to the veteran’s claim that he had used this 
medication for more than 10 years.  

The examiner found that it was clinically possible that when 
Mellaril was used in dosages exceeding 800 milligrams for a 
long period of time that it would indeed cause optical 
damage.  It was usually felt that once the medication was 
discontinued, the vision returned to normalcy.  The examiner 
noted that enough evidence could not be found in the 
documentation to indicate that the veteran had used any of 
this medication greater than the 600 milligrams per day as he 
claimed, and certainly not for the length of time claimed.  

It was theoretically possible that the medication could have 
caused some damage.  The examiner noted the Mellaril was very 
likely originally prescribed for him due to the symptoms of 
post traumatic stress disorder.  The conclusion was that this 
would have been the use of the medication in his case during 
the three years of treatment.

Analysis

Service connection may be granted for a disorder which is 
proximately due to or the result of a service-connected 
disability.  38 C.F.R. § 3.310(a).

The Board’s review of the evidence of record permits the 
conclusion that the record supports a grant of entitlement to 
service connection for defective vision as secondary to 
medication taken for treatment of service connected post 
traumatic stress disorder.

In this regard the Board notes that the post service medical 
record is replete with references to medication; in 
particular, Mellaril (Thiorizdazine) administered by VA to 
the veteran for treatment of his psychiatric symptomatology 
ultimately diagnosed as post traumatic stress disorder.  

The specific quantity of such medication and its specific 
dosage over the years has at times been indeterminate; 
nonetheless, the record is sufficiently complete to permit 
the conclusion that the principal medication utilized by VA 
for treatment of post traumatic stress disorder has been 
Mellaril.

VA specialists in ophthalmologic diseases have repeatedly 
expressed in writing the opinion that that veteran’s 
bilateral defective vision was entirely consistent with 
Mellaril toxicity.  His retinopathy had been noted to be 
induced by Mellaril.  The most recent opinion on file by VA 
psychiatrists consisted of several indeterminate statements 
couched in vague suppositions as to the medical evidence of 
record with respect to the quantity of medication taken by 
the veteran for his service-connected post traumatic stress 
disorder.  The opinion was not expressed in conclusory 
language; nonetheless, the examiners acknowledged that vision 
damage was to be expected under the purported treatment 
regimen undergone over the years by the veteran to control 
the disabling manifestations of post traumatic stress 
disorder.

The Board finds that the most recent statement on file by VA 
psychiatrists does not diminish the persuasive nature of the 
earlier definitive opinions rendered by VA specialists in 
ophthalmology linking the administration of Mellaril for 
treatment of service-connected post traumatic stress disorder 
to the development of defective vision.  The fact that the 
record shows the veteran complained of vision problems prior 
to commencement of treatment of post traumatic stress 
disorder with Mellaril is of no clinical consequence as the 
evidence shows that bilateral vision damage has been 
specifically linked to the Mellaril medical treatment 
regimen.

For the foregoing reasons the Board concludes that the record 
supports a grant of entitlement to service connection for 
defective vision as secondary to medication taken by the 
veteran for treatment of service-connected post traumatic 
stress disorder.  38 U.S.C.A. § 5107;  38 C.F.R. § 3.310(a).


II.  Entitlement to an increased 
evaluation for post traumatic stress 
disorder, currently evaluated as 50 
percent disabling.

Factual Background

A March 1984 private psychiatric examination concluded in a 
diagnosis of post traumatic stress disorder.

The Board of Veterans’ Appeals (Board) granted entitlement to 
service connection for post traumatic stress disorder in 
August 1984.

The RO implemented the August 1984 determination of the Board 
when it issued a rating decision in October 1984 establishing 
service connection for post traumatic stress disorder with 
assignment of a 50 percent evaluation.

The veteran was hospitalized by VA in February 1989 for 
treatment of post traumatic stress disorder and episodic 
alcohol abuse.  

A May 1989 VA fee basis special psychiatric examination shows 
the veteran demonstrated symptomatology of exaggerated 
startle response, reduced involvement in the external world, 
avoidance of activities that recalled trauma, sleep 
disturbance with combat related nightmares, reexperiencing 
the traumatic event, flashbacks, and guilty feelings.  
Symptoms of depression included depressed mood, sleep and 
appetite disturbance, fatigue, anhedonia, low self-esteem, 
suicidal ideation, and impaired concentration.  The 
examination diagnoses were post traumatic stress disorder, 
major depression, and alcohol dependence.

In an August 1989 application for increased compensation 
based on unemployability the veteran reported he had become 
too disabled to work in August 1968, upon discharge from 
service.  He indicated he had completed eight years of grade 
school.

The veteran was hospitalized by VA in April 1990 for 
treatment of post traumatic stress disorder.  He reported he 
was feeling very nervous and unable to cope with the stress 
at home.  He also complained of nightmares and flashbacks.  
He was tense, anxious, shaky and irritable.  He felt 
depressed and hopeless.  Affect was depressed.  The appellant 
was oriented times three.  Memory was intact.  He lacked 
insight and judgment was poor.

The appellant was hospitalized by VA for treatment of post 
traumatic stress disorder in December 1990.  The veteran 
stated that he went to pieces when his son who is mentally 
handicapped was jailed for possession of a gun while on 
probation.  The appellant stated that he could not do 
anything about it.  As a result he became depressed, feeling 
hopeless and helpless.  He stated that he also had flashbacks 
about Vietnam.  He was always uptight when sleeping.  When 
someone touched him he automatically jumped.

A February 1992 fee basis psychiatric examination for VA 
compensation purposes shows the veteran was somewhat 
disjointed because of his agitation, nervousness and 
emotionality to the degree that he continually began talking 
about traumatic combat events regardless of the topic of 
conversation.  This agitation also included constant pacing 
and hypervigilance.  The veteran reported that although his 
drinking had decreased, he continued to drink approximately 
twelve beers in a three day period because of symptoms of 
post traumatic stress disorder.

The veteran was hospitalized by VA for treatment of post 
traumatic stress disorder in April 1992, due to flashbacks, 
nightmares of Vietnam, feeling anxious, and despondency due 
to his son’s legal problems and his own failing eyesight.  
The appellant admitted to drinking 6 to 10 beers per day 
lately and recently had some problems with anger control.  
While in admissions he became violent and was subdued by 
security.  The current Global Assessment of Functioning Score 
was 15.  The highest score during the prior year had been 80.

The veteran was hospitalized by VA for treatment of post 
traumatic stress disorder during July and August 1992.  He 
reported he had been sober for the past two to three years 
until the last two weeks when he began drinking 15 to 20 
beers daily.  He stated he could no longer take any more of 
the flashbacks and nightmares about Vietnam experiences.  The 
appellant stated that during his nightmares he had been 
hearing the screaming of young kids he accidentally shot 
while on the battlefield.

During a March 1993 VA special psychiatric examination the 
veteran reported he had been unemployed since separation from 
service.  He admitted to depression and suicidal thoughts.  
His symptoms were said to be present since Vietnam.  The 
claimant stated that nightmares were constant.  He could not 
stand being around people.  The appellant stated he had lost 
his pride and his dignity.  On mental status interview his 
mood was sad and depressed.  Affect was constricted but 
appropriate.  The pertinent diagnoses were post traumatic 
stress disorder, chronic; and alcohol abuse, continuous.

The appellant was hospitalized by VA for treatment of post 
traumatic stress disorder during April and May 1993.  He 
reported having been drinking 6 to 8 beers per day for the 
past two weeks.  The appellant reported not having worked 
since service and to have quit school in the 9th grade.  
Insight was lacking and judgment was poor.  

A service representative testified on behalf of the veteran 
at an RO hearing held in January 1994.  The service 
representative testified as to the disabling manifestations 
of the appellant’s post traumatic stress disorder with 
alcoholism.

A March 1994 VA special psychiatric examination concluded in 
a relevant diagnosis of post traumatic stress disorder.

The veteran was treated for post traumatic stress disorder 
with alcohol dependence when hospitalized by VA during 
February and March 1994.  He reported feeling nervous with 
flashbacks of Vietnam.  He had concerns he was feeling angry 
toward his family.  Insight was lacking and judgment was 
poor.  The discharge diagnosis was post traumatic stress 
disorder with alcohol dependence.  The Global Assessment of 
Functioning Score was 50 for the present year, and 55 for the 
prior year.

The appellant was hospitalized by VA for treatment of post 
traumatic stress disorder in August 1994.  He voluntarily 
came to the hospital because he was having flashbacks and 
nightmares from his Vietnam experience.  His nerves had been 
getting the best of him basically because he was going blind.  
Three weeks previously he had run out of medication and this 
contributed to his nervous feelings, flashbacks, and 
nightmares.  

On examination the veteran’s affect was appropriate to mildly 
depressed mood.  Judgment was poor and insight was lacking.  
At the time of discharge he was alert, coherent and relevant.  
He was well oriented in all spheres and his memory was 
intact.  The pertinent discharge diagnosis was post traumatic 
stress disorder.  The Global Assessment of Functioning Score 
was 51 for the present year and during the previous year.

The claimant was hospitalized by VA for treatment of post 
traumatic stress disorder with alcohol dependence during 
October and November 1994.  He had been having nightmares and 
feeling depressed.  His affect was mildly depressed.  Insight 
was lacking and judgment was poor.  The relevant discharge 
diagnosis was post traumatic stress disorder.  The Global 
Assessment of Functioning Score was 55 for the current year, 
and 60 during the previous year.

The veteran was hospitalized by VA for treatment of post 
traumatic stress disorder with alcohol dependence during July 
and August 1995.  He had been feeling nervous and depressed, 
and had not been sleeping well.  He had been having 
nightmares and drinking a case of beer daily for two to three 
weeks.  

On mental status examination the appellant’s affect was 
mildly depressed.  Insight was lacking and judgment was poor.  
The pertinent discharge diagnosis was post traumatic stress 
disorder with alcohol dependence.  The Global Assessment of 
Functioning Score was 40 for the current year, and 45 for the 
prior year.

On file are VA psychotherapy reports pertaining to treatment 
of the veteran during the 1990’s.


Analysis

The veteran’s post traumatic stress disorder with alcoholism 
is rated as 50 percent disabling under diagnostic code 9411 
of the VA Schedule for Rating Disabilities.  The 50 percent 
evaluation contemplates considerable social and industrial 
impairment.  The next higher evaluation of 70 percent is 
warranted for severe social and industrial impairment.  The 
maximum schedular evaluation of 100 percent requires that the 
attitudes of all contacts except the most intimate be so 
adversely affected as to result in virtual isolation in the 
community.

Alternatively, totally incapacitating psychoneurotic symptoms 
bordering on gross repudiation of reality with disturbed 
thought or behavioral processes associated with almost all 
daily activities such as fantasy, confusion, panic and 
explosions of aggressive energy resulting in profound retreat 
from mature behavior warrant a 100 percent evaluation.  
Finally, a 100 percent evaluation is warranted if a veteran 
is demonstrably unable to obtain or retain employment due to 
post traumatic stress disorder with alcoholism.  38 C.F.R. 
§ 4.132.  This is the veteran’s case.

The Board’s review of the evidentiary record discloses that 
the veteran has been hospitalized on numerous occasions to 
reduce symptomatology associated with post traumatic stress 
disorder and for detoxification due to chronic alcohol abuse, 
a manifestation of his over-all psychiatric illness.  The 
veteran has required psychotherapy on an outpatient basis 
periodically, but this has not been sufficient.  

The veteran has required numerous admissions in an attempt to 
return him to some semblance of peace of mind.  However, as 
the record shows, the veteran has been subject to intensive 
exacerbations of his psychiatric symptomatology which has 
required inpatient care.

The appellant has not been employed since separation from 
service.  Information of record shows he has been in receipt 
of Social Security disability benefits for many years.  The 
substantial quantity of VA records of inpatient and 
outpatient treatment over many years shows that the appellant 
is always deeply affected by the events in his life and he 
has no social life to speak of.  He remains vulnerable to 
intensification of his psychiatric symptomatology which in 
effect renders him unable to cope with the ordinary stresses 
in a non-industrial, much less industrial environment.  

It is clear from the record that the appellant is unable to 
acclimate himself in a social or industrial setting.  He is 
for all intents and purposes isolative in his daily existence 
which unfortunately involves abuse of alcohol as a 
manifestation of his service-connected psychiatric 
disability.  His absence from the labor market since 
separation from service and social isolation of many years 
standing has rendered him a poor candidate for even the most 
minimal kind of employment.

From a review of the record it appears unlikely that the 
veteran could return to a structured environment as he is 
unable to withstand the pressures of his life style of many 
years which has involved no meaningful social or industrial 
interaction.  Accordingly, at least three of the rating 
criteria for a 100 percent rating are independently met in 
the veteran’s case.  See Johnson v. Brown, 7 Vet.App. 95, 97 
(1994).  

In this regard, the veteran is socially isolated, he suffers 
from disturbed thought and behavioral processes associated 
with almost all daily activities particularly in view of his 
alcohol abuse, and most of all the veteran with his record 
number of hospitalizations over the years is demonstrably 
unable to work.  

For the foregoing reasons, the Board concludes that the 
record supports a grant of entitlement to a 100 percent 
evaluation for post traumatic stress disorder with 
alcoholism.  38 U.S.C.A. §§ 1155, 5107;  38 C.F.R. §§ 
3.321(b)(1), 4.7, 4.132, Diagnostic Code 9411.


ORDER

Entitlement to service connection for defective vision as 
secondary to medication taken for service-connected post 
traumatic stress disorder is granted.

Entitlement to a 100 percent evaluation for post traumatic 
stress disorder is granted, subject to governing criteria 
applicable to the payment of monetary benefits.



		
	BRUCE KANNEE
	Member, Board of Veterans' Appeals

The Board of Veterans' Appeals Administrative Procedures 
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 
(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 
1991 &  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, 102 Stat. 4105, 4122 (1988).  The 
date which appears on the face of this decision constitutes 
the date of mailing and the copy of this decision which you 
have received is your notice of the action taken on your 
appeal by the Board of Veterans' Appeals.
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