Citation NR: 9612913 Decision Date: 05/10/96 Archive Date: 05/21/96 DOCKET NO. 94-29 686 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for myopia. 2. Entitlement to service connection for fingernail loss. 3. Entitlement to an increased (compensable) evaluation for psoriasis. ATTORNEY FOR THE BOARD Jeanne Schlegel, Associate Counsel INTRODUCTION The veteran served on active duty from November 1980 to November 1984 and from March 1985 to December 1992. This matter comes before the Board of Veterans' Appeals (the Board) from a June 1993 rating determination by the Department of Veterans Affairs (VA) Regional Office (RO) which denied the claims of entitlement to service connection for myopia and loss of fingernails and granted service connection for psoriasis, assigning a noncompensable evaluation. In January 1996, the RO denied service connection for psoriatic arthritis holding that the veteran had not submitted a well grounded claim. The veteran was furnished a copy of the decision in March 1996. The matter is not properly before the Board for appellate consideration at this time. 38 C.F.R. § 20.200 (1995). The issues of service connection for myopia and fingernail loss are discussed in the remand that follows this decision on the issue of an increased rating for psoriasis. Finally, the Board notes that it does not appear that the RO has considered the issue of entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1995) for the service- connected disability at issue in this appeal. Though a separate issue, the Board is obliged to raise it based upon a liberal reading of documents and testimony of record. However, the matter must be initially reviewed by the RO. Consequently, the matter is now referred to the RO for appropriate further action. Floyd v. Brown, No. 92-970 (U.S. Vet. App. Apr. 17, 1996); Fisher v. Principi, 4 Vet.App. 57, 60 (1990). CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that his psoriasis should be compensably evaluated. 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 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 evidence warrants an increased evaluation for psoriasis. FINDING OF FACT The veteran's psoriasis is manifested primarily by several erythematous, scaly patches on the scalp. CONCLUSION OF LAW The criteria for a 10 percent evaluation for psoriasis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.7, Codes 7806, 7816 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran’s claim is well grounded and that all relevant facts have been developed to allow for an informed determination on the current record of the level of disability from psoriasis. The Board observes that the veteran is currently in receipt of a separate evaluation of 30 percent for acne. By rating action of June 1993, service connection was granted for psoriasis for which a noncompensable evaluation was assigned on the basis of pertinent historical and current medical records. A VA examination was conducted in January 1993. The veteran complained of acne and psoriasis. He indicated that psoriasis appeared as a problem separate from acne and consisted of a small area of rash present on the scalp, decreasing and increasing in size over the years. His current symptoms were described as minimal, and the veteran indicated that the condition had never involved the elbows, knees, or other body parts. An examiner reported a small area of thickening, redness and scaling of the right parietal area of the scalp. No abnormality of the eyes was noted. The dermatology diagnosis was chronic and acute acne with residual scarring. A VA examination was conducted in June 1994. The veteran reported that in 1983 he had scalp, knee, and elbow problems which were diagnosed as psoriasis. A physical examination of the skin revealed several erythematous, scaly patches in the scalp. The elbows and the knees were unaffected. The pertinent assessment was psoriasis vulgaris. Psoriasis is evaluated as for eczema under the provisions of 38 C.F.R. § Part 4, Code 7806. As with eczema, the evaluation will depend upon the location and extent of the disease and the repugnant disfigurement or other disabling characteristics of the manifestations of the disease. 38 C.F.R. § Part 4, Code 7816. A noncompensable evaluation is warranted for psoriasis with slight, if any, exfoliation, exudation or itching which is on a nonexposed surface or small area. A 10 percent evaluation requires exfoliation, exudation or itching and involvement of an exposed surface or extensive area. A 30 percent evaluation requires constant exudation or itching, extensive lesions, or marked disfigurement. 38 C.F.R. § Part 4, Code 7806. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). At the time of the VA examination in 1993, the veteran reported minimal symptoms with respect to psoriasis and involvement was limited apparently to a singular patch of the scalp. However, on reexamination in June 1994, several erythematous scaly patches were present on the scalp. In view of the recent description of the character and extent of the veteran’s psoriasis, the Board finds that the disability more nearly approximates the criteria for a 10 percent evaluation. The critical criteria for a 30 percent rating have not been reported on either examination. However, overall, the disability appears to have become more extensive in the scalp and consequently warrants a 10 percent rating at this time. 38 C.F.R. § 4.7. ORDER An increased evaluation for psoriasis is granted to the extent indicated, subject to the regulations governing the payment of monetary awards. REMAND The veteran contends that service connection is warranted for myopia, and loss of fingernails. The veteran contends that myopia and loss of depth perception has resulted from the athermal bioeffects of microwave exposure sustained during service when he was a radar technician. In addition, the veteran also argues that Accutane therapy for acne resulted in loss of fingernails. The DD Form 214 for the veteran’s second period of active service reflects a primary specialty of light wheel vehicle mechanic. However, service medical records from his earlier service refer to duty as a radar technician. Service medical records revealed that the veteran’s distant vision was 20/20 in the right eye and 20/25 in the left eye at the time of his physical examination for enlistment with distant vision of 20/40 and 20/25, respectively on an October 1984 separation examination with no eye diagnosis reported on either occasion. The records on file for his second period of service include evaluations for eye complaints. In April 1987, an examiner reported myopia, astigmatism and exotropia. Strabismus was subsequently reported. Neither VA examination included an acceptable evaluation of the veteran’s eyes to allow for an informed determination, as the record does not include an acceptable evaluation. That is, one that comprehensively sets forth the nature and probable etiology of any eye pathology present . The Board recognizes that 38 C.F.R. § 3.303(c) (1995), (1995) provides that refractive error of the eye is not a disease or injury within the meaning of applicable legislation governing the awards of compensation benefits and that myopia is listed as a type of refractive error in the current VA Manual M21-1 (M21-1), Part 6, § 7.09. However, the pertinent guidance in M21-1 does not rule out service connection for myopia entirely. It also appears from the manual provisions that a medical opinion must be obtained to properly evaluate the claim. See, for example, Colvin v. Derwinski, 1 Vet.App. 171 (1991). Regarding the claim for service connection of fingernail loss, the Board notes that an August 1985 service medical record entry mentions pitting of a fingernail in describing the extent of the veteran’s psoriasis. He subsequently was prescribed Accutane, initially in June 1988. Although the veteran complained of this condition upon VA examinations in both January 1993 and June 1994, and at both times the veteran presented this theory as to the relationship between his fingernail condition and Accutane treatment, at neither time were any findings of a nail abnormality noted, nor was a pertinent diagnosis made, nor was a competent medical opinion establishing a relationship between Accutane treatment and nails loss offered by the VA examiners. However, the question of such a relationship was directly posed to the dermatology examiner in 1994, but no opinion was provided. An examiner of the veteran’s joints deferred such an opinion to the dermatology examiner. A medical examination must specifically address pertinent issues and the silence of an examiner cannot be relied on as evidence against a claim. Wisch v. Brown, 8 Vet.App. 139 (1995). Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he provide the names, addresses and approximate dates of treatment for all health care providers from whom the veteran received treatment for any eye or fingernail disability since service. With any necessary authorization from the veteran, the RO should attempt to obtain copies of any treatment records identified by the appellant that have not been previously secured. The veteran should be afforded the opportunity to submit competent scientific or medical evidence that any confirmed eye disability is a radiogenic disease. He should also be asked whether he received a medical examination prior to his separation from service in December 1992. If so, the RO should proceed accordingly. 2. Thereafter, if the veteran submits the competent scientific or medical evidence requested in paragraph 1, the RO should undertake any other indicated development under 38 C.F.R. § 3.311(b). 3. Thereafter, the veteran should be scheduled for an examination by a specialist in eye disorders to determine the nature, extent, onset and probable etiology of any eye disability found. The examiner should conduct the evaluation mindful of the provisions found in VA Manual M21-1 (M21-1), Part 6, § 7.09. The specialist should be requested to review the claims file and provide an opinion as to whether any myopia or other eye disability found meets the exceptions to the general rule regarding service connection for refractive error or any other listed eye disorder. A complete rationale should be offered for all opinions and conclusions expressed. 4. The veteran should be afforded comprehensive VA dermatology examination to determine the current extent, severity and probable etiology of any fingernail disorder found. The claims folder must be made available to the examiners for review in conjunction with the examination. With respect to the foregoing, regarding any fingernail disorder found, the examiner, after review of the claims folder, should provide an opinion regarding the significance of medical treatment for a service-connected skin disorder, specifically the use of Accutane, in the development of or the severity of any disorder of the fingernails found. In responding to these questions, the examiner should provide the rationale for all conclusions and opinions expressed. Any consultations with other specialists deemed necessary for a comprehensive evaluation should be obtained. 5. Thereafter, the RO should undertake any other indicated development and readjudicate the issues on appeal. If any benefit sought on appeal is not granted, a supplemental statement of the case should be issued and the appellant and his representative provided the applicable period in which to respond. Thereafter, the case should be returned to the Board for further consideration, if in order. By this REMAND, the Board intimates no opinion as to the final outcome warranted. No action is required of the appellant until he is notified by the RO. MARK J. SWIATEK Acting 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 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 -