Citation Nr: 18139634
Decision Date: 09/28/18	Archive Date: 09/28/18

DOCKET NO. 13-16 602
DATE:	September 28, 2018
ORDER
Entitlement to service connection for a bilateral eye condition, other than allergic conjunctivitis and blepharitis, to include glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia is denied.
FINDINGS OF FACT
1. The probative evidence does not demonstrate that the Veteran’s currently diagnosed glaucoma suspect manifested during, or as a result of, active military service, or was caused by or aggravated by any service-connected disability.
2. The probative evidence does not demonstrate that the Veteran’s currently diagnosed chronic canaliculitis manifested during, or as a result of, active military service, or was caused by or aggravated by any service-connected disability.
3. The probative evidence does not demonstrate that the Veteran’s currently diagnosed medial pinguecula manifested during, or as a result of, active military service, or was caused by or aggravated by any service-connected disability.
4. The probative evidence does not demonstrate that the Veteran’s currently diagnosed nuclear sclerotic cataracts manifested during, or as a result of, active military service, or was caused by or aggravated by any service-connected disability.
5. The Veteran’s hyperopia and presbyopia are not recognized disabilities of the eyes for VA compensation purposes; there is no evidence of an additional disability due to disease or injury superimposed upon the hyperopia and presbyopia during service.
CONCLUSION OF LAW
The criteria for entitlement to service connection for a bilateral eye condition, other than allergic conjunctivitis and blepharitis, to include glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia have not been met.  38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.9 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The Veteran served on active duty from September 1974 to June 1977.  This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a May 2011 rating decision.
The Veteran was afforded a hearing before the undersigned Veterans Law Judge in August 2014.
In April 2015, October 2015, November 2017, and April 2018, the Board remanded this claim for additional evidentiary development.
1. Entitlement to service connection for a bilateral eye condition, other than allergic conjunctivitis and blepharitis, to include glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia
Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby.  38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). 
Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).  Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service.  38 C.F.R. § 3.303 (d) (2017).
Service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury.  To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) nexus evidence establishing a connection between the current disability and the service-connected disability.  Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995).
Service connection may be granted for diseases, but not defects, of congenital, developmental, or familial origin.  See 38 C.F.R. 3.303 (c), 4.9; Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009); Monroe v. Brown, 4 Vet. App. 513, 515 (1993).  Defects are typically static conditions which are incapable of improvement or deterioration.  VAOPGCPREC 67-90.  In contrast, a disease refers to a condition considered capable of improving or deteriorating.  VAOPGCPREC 67-90.  However, if the defect was aggravated such that a superimposed disease or injury occurred during service, service connection may be established for the resultant disability.  VAOPGCPREC 82-90.
In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature.  Grottveit v. Brown, 5 Vet. App. 91, 93 (1993).  In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology.  Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 
Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features.  Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 
Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms.  Charles v. Principi, 16 Vet. App. 370, 374 (2002).
Turning to direct service connection, the Veteran contends that his bilateral eye conditions are due to going through a simulated fire and experiencing strong gases during basic training.
The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.
The Board concludes that, while the Veteran has current diagnoses of glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia, and evidence shows that the Veteran was exposed to gases and was seen for burning, pain, and redness in the eyes, the preponderance of the evidence weighs against finding that the Veteran’s diagnoses of dry eyes, glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts began during service or is otherwise related to an in-service injury, event, or disease.  38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d).
The July 2015 VA examination shows the Veteran was not diagnosed with bilateral glaucoma suspect and bilateral pinguecula nasal until March 2011, approximately 34 years after his separation from service; with chronic canaliculitis left eye until February 2012, approximately 35 years after separation from service; and bilateral nuclear sclerotic cataract until July 2015, approximately 38 years after separation from service.  While the Veteran is competent to report having experienced symptoms of painful eyes, burning red eyes, blurred vision, eye irritation, and watering in both eyes consistently since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia.  The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing.  Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  
Taken together, the April 2017 and December 2017 VA examiner’s opinions establish that the Veteran’s glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts are not at least as likely as not related to an in-service injury, event, or disease, including exposure to gases in a simulated fire and red, burning, and painful eyes experienced in service.  The April 2017 VA examiner opined that the Veteran’s glaucoma suspect status was not at least as likely as not related to exposure to gases while in service, and restated in the December 2017 VA examination that the Veteran’s glaucoma suspect status was not at least as likely as not related to exposure to gases while in service.  The combined rationale was that the Veteran had no history of eye trauma and that glaucoma suspect status occurs in the general population and can be hereditary in nature.  The examiner’s opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).
The April 2017 VA examiner opined that the Veteran’s chronic canaliculitis was not at least as likely as not related to exposure to gases while in service, and restated in the December 2017 VA examination that the Veteran’s chronic canaliculitis was not at least as likely as not related to exposure to gases while in service.  The combined rationale was that canaliculitis is caused by infection of the canaliculus.  It is more often caused by a bacterial pathogen, and the infection causes small dacryoliths, or stones, to form.  It can occur in individuals over the age of 40.  Here, the Veteran had a stone successfully excised in February 2012 and had good resolution at his three-month follow-up.  The examiner also reasoned that lacrimal canaliculitis can often be a cause of non-resolving bacterial or viral conjunctivitis, however there was no evidence of treatment for those types of conjunctivitis.  The Veteran showed no history of chronic bacterial or viral conjunctivitis in his past notes.  The examiner’s opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). 
The April 2017 VA examiner opined that the Veteran’s bilateral nasal pinguecula was not at least as likely as not related to exposure to gases while in service, and restated in the December 2017 VA examination that the Veteran’s bilateral nasal pinguecula was not at least as likely as not related to exposure to gases while in service.  The combined rationale was that pinguecula is a common type of conjunctival degeneration in the eye.  It is a common finding in the older demographic as our eyes have had longer term UV exposure with advancing age.  It is a benign condition occurring in the general population and requiring no treatment.  The Veteran’s pinguecula are not inflamed.  The examiner’s combined opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).
The December 2017 VA examiner opined that the Veteran’s nuclear sclerotic cataract was not at least as likely as not related to exposure to gases while in service.  The rationale was that a cataract is a clouding of the lens in the eye leading to a decrease in vision.  They are most commonly due to aging and occur in the general population.  The examiner stated the Veteran has age-appropriate presentation of the cataract.  The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).
Moreover, the April 2017 VA examiner stated that it is less likely than not that the Veteran’s exposure to gases from a fire structure while in service caused any eye diagnoses.  The examiner reasoned the Veteran was exposed to gases in basic training, approximately between September 1974 to November 1974, and it made his eyes burn and water.  The Veteran did not seek medical evaluation after this exposure.  The Veteran’s STRs state the Veteran had burning, irritated eyes for three years prior to December 1975.  The Veteran made additional complaints in February 1976, July 1976, February 1980 and November 1980.  He was examined at those times and ophthalmology found no pathology or acute problems.  Upon the July 2015 VA examination, the Veteran’s corneas appeared healthy, tear film was intact, and there were no signs of ocular surface disease related to fire exposure to both eyes.  Eyelid margins appeared healthy and did not show erythema, debris, or excess oils.  There was no tenderness or expressed mucus from the eyelids and no chalazion in either eye.
While the Veteran believes his glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts are related to an in-service injury, event, or disease, including exposure to gases in service, he is not competent to provide a nexus opinion in this case.  This issue is also medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  Consequently, the Board gives more probative weight to the VA examiner’s opinions.
Turning to secondary service connection, the Veteran contends that his glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts were caused or aggravated by his service-connected allergic conjunctivitis or blepharitis.
The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability.
The Board concludes that, while the Veteran has current diagnoses of glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts, the preponderance of the evidence is against finding that the Veteran’s glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts are proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability.  38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a).
The April 2017 VA examiner opined that the Veteran’s glaucoma suspect occurs in the general population and is instead more likely hereditary.  The rationale was that there is no history of eye trauma and the Veteran was diagnosed in March 2011.
The April 2017 VA examiner opined that the Veteran’s canaliculitis is instead more likely due to chronic bacterial or viral conjunctivitis.  The rationale was that there is no evidence of treatment for these types of conjunctivitis, as noted in the Veteran’s February 1976 Service Treatment Record (STR).
The April 2017 VA examiner opined that the Veteran’s bilateral nasal pinguecula is a common finding in the older demographic and instead more likely due to long term UV exposure with advancing age.  The rationale was that it was diagnosed in March 2011, is a common type of conjunctival degeneration in the eye, and occurs in the general population.
The April 2017 VA examiner opined that the Veteran’s nuclear sclerotic cataract is instead more likely due to aging.  The rationale was that it was diagnosed in 2015, is an age-appropriate presentation of cataract for the Veteran, and occurs in the general population.
Moreover, the May 2018 VA addendum opinion stated it is less likely than not that the Veteran’s conditions (glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts) were aggravated beyond their natural progression by the Veteran’s service-connected allergic conjunctivitis or blepharitis.  The rationale was that there is no study linking any of these conditions to allergic conjunctivitis or blepharitis.
While the Veteran believes his glaucoma suspect, chronic canaliculitis, medial pinguecula, and nuclear sclerotic cataracts are proximately due to or aggravated beyond their natural progression by service-connected disability, he is not competent to provide a nexus opinion in this case.  The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  Consequently, the Board gives more probative weight to the VA examiner’s opinion and addendum opinions.
Refractive error of the eye is not a disease or injury for VA purposes.  38 C.F.R. § 4.9.  Hyperopia, also called farsightedness, has been defined as a defect of vision in which parallel light rays reaching the eye come to focus behind the retina, vision being better for distant objects than for near. “Hyperopia,” Dorland’s Medical Dictionary for Health Consumers (2007). https://medical-dictionary.thefreedictionary.com/hyperopia (last viewed September 27, 2018).  Presbyopia, also called nearsightedness, has been defined as a condition that occurs as a part of normal aging and is not considered to be an eye disease. The process occurs gradually over a number of years. Symptoms are usually noticeable by age 40-45 and continue to develop until the process stabilizes some 10-20 years later. Presbyopia occurs without regard to other eye conditions.  “Presbyopia,” Dorland’s Medical Dictionary for Health Consumers (2007). https://medical-dictionary.thefreedictionary.com/presbyopia (last viewed September 27, 2018).
Moreover, the December 2017 VA examiner stated that hyperopia, or farsightedness, is a vision condition in which distant objects are usually seen clearly, but close ones do not come into proper focus.  This occurs if your eyeball is too short or the cornea has too little curvature, so light entering your eye is not focused correctly.  This refractive error is common in the general population and hereditary in nature.  Presbyopia is a condition associated with aging in which the eye exhibits a progressively diminished ability to focus on near objects.  This refractive error is due to aging and occurs in the general population.  The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).
Though the Veteran has current bilateral eye conditions, the record shows he was diagnosed with hypotropia and presbyopia in March 2011. Both of these conditions constitute a congenital defect for VA purposes, and are not entitled to service connection.  The record fails to persuasively show that the Veteran’s congenital defect was subject to a superimposed disease or injury in service.  The April 2017 VA examiner stated that it was less likely than not that any developmental conditions of the eyes were subject to increased disability from exposure to strong gases.  The rationale was that the Veteran showed no signs of ocular sequelae.  At the July 2015 VA examination, the Veteran’s corneas appeared healthy, his tear film was intact, and there were no signs of ocular surface disease related to fire exposure to both eyes.  There is no subepithelial punctuate keratitis in both eyes.  His eyelid margins appear healthy and show no erythema.  The Veteran’s retinal healthy is good in both eyes.  Therefore, service connection for hyperopia and presbyopia is not warranted.
In sum, the Board finds that service connection for bilateral eye condition, including glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia is not warranted.

In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine.  However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable.  See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990).

 
TANYA SMITH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Alexia E. Palacios-Peters, Associate Counsel 

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