Citation Nr: 18123959
Decision Date: 08/03/18	Archive Date: 08/03/18

DOCKET NO. 15-03 883
DATE:	August 3, 2018
Entitlement to service connection for residuals of concussion or traumatic brain injury (TBI), claimed as head injury, is remanded.
Entitlement to service connection for seizures, claimed as residual of head injury is remanded.
Entitlement to service connection for right eye condition is remanded.
The Veteran served on active duty from July 1978 to July 1982.
The Veteran was scheduled for a hearing in July 2018, but the Veteran did not appear and he did not request an additional hearing in fifteen days from the date of the hearing, as informed. The May 2018 hearing letter was not returned as undeliverable. Accordingly, the Veteran’s hearing request is considered withdrawn.  See 38 C.F.R. § 20.704(d). 
In his August 2012 notice of disagreement, the Veteran contends that he suffered an accident while aboard a maintenance barge when a steel catwalk ladder fell on top of him, he received injuries to his head, face, and other parts of the body, and he experienced headaches, short-term memory loss, and seizures since then. He explained that because the conditions were not too severe at the time, medical treatment was not sought and he self-medicated with over-the-counter medication. As his conditions increased in severity, he began to seek VA treatment. 
With regard to his right eye condition, he explained that the flame from a welding torch damaged his vision and at times when he was not welding, flames from welding around him contributed to his vision problem. 
Regarding his claimed TBI and residuals, to include concussion and seizures, the VA examiner provided diagnosis of concussion with no LOC, and opined that it was not at least as likely incurred in or caused by his in-service injury because there is no evidence for any treatment for residuals of concussion, such as headaches, seizures, memory loss, and although STRS noted a head injury, these symptoms were not noted, and the separation examination was normal. He noted the first documentation of seizures was most likely secondary to alcohol withdrawal when he sought VA treatment. 
In an October 2011 addendum opinion, the VA examiner added that there was no other evidence of and or treatment for residuals due to concussion and that the Veteran has a history of alcohol abuse which could be contributing to cognitive, behavioral impairments, psychiatric symptoms and loss of balance, therefore less likely due to concussion and the Veteran’s reported headaches triggered by heat/sun are most likely due to dehydrations, and less likely due to concussion. 
The VA examiner relied largely on the lack of documented complaints, diagnosis, and treatment in service, without specifically addressing the Veteran’s assertions as to experiencing continued headaches, memory loss, and seizures since the documented accident in service.  See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (examination inadequate where the examiner relied on the lack of evidence in service treatment records to provide negative opinion). Here, the June 2011 VA examiner notes the Veteran’s symptoms of headaches, seizures, memory loss, depression, but did not address these symptoms and whether they were residuals of a TBI. Further, although the examiner indicated his seizures were related to alcohol withdrawal, the VA treatment records reflect the Veteran continued to drink alcohol and continued to experience seizures. 
In addition, the Board notes that a November 2014 VA treatment record indicates the Veteran had a CT scan of the brain, which showed frontotemporal hemorrhage. The results of the CT scan are not associated with the record, and thus must be obtained and addressed.  
With regard to the Veteran’s claimed right eye condition, the May 2011 VA examiner noted diagnoses of right eye dryness and cornea scar.  The examiner explained that injury from a welder’s arc, flash burn, causes foreign body sensation, irritation, pain, photophobia, tearing, blepharospasm, and decreased acuity, 6-12 hours after exposure. The Veteran had no corneal involvement and full recovery typically occurs in 24-76 hours. Prolonged exposures to UV radiation can lead to chronic solar toxicity, which is associated with several ocular surface disorders. Rarely, retinal absorption of visible to near-infrared radiation from welding arcs can lead to permanent, sight threatening injury. 
The Board, however, notes that the STRs reflect that in July 1980 that a radiator from a car exploded causing first and second degree burns to his upper body, including his chest, arms, eyes, and face area, but the examiner did not address this particular incident and only addressed a flash burn related to an in-service April 1979 incident  and UV exposure. The examiner also did not address the etiology of right eye corneal scar found upon examination, as well as the Veteran’s report of continued vision loss since service. 
In light of the above deficiencies, the Board finds that additional opinions are necessary. 
As the matter is being remanded, and it appears that the Veteran continues to receive treatment through VA, updated VA treatment records should also be obtained.  See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016).
The matters are REMANDED for the following action:
1. Obtain any outstanding updated VA treatment records, to include the brain CT scan referenced in the November 2014 VA treatment record.
2. Schedule the Veteran for a VA examination, with a qualified VA physician to identify and determine the nature and etiology any residuals of a TBI/concussion, to include seizures, loss of memory, headaches.  The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the report that the claims file was reviewed.
Based on the examination and review of the record, the examiner should clearly identify all residuals of the asserted TBI/concussion found since approximately December 2010, to include reported headaches, memory loss, loss of balance, seizures, and depression, and then should determine whether it is as least as likely as not (50 percent probability or more) that the it had its onset during service or was otherwise causally or etiologically related to service, to include the Veteran’s in-service head injury.  In answering this question, the physician should address the Veteran’s contention as to continuity of his symptoms during and since service, and that he self-treated his symptoms. The physician should address the November 2014 CT scan, reflecting frontotemporal hemorrhage. 
A complete rationale should accompany any opinion provided.
The absence of evidence of treatment for a particular TBI disorder in the Veteran’s service treatment records or post-service records cannot, standing alone, serve as the basis for a negative opinion.
The examiner is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account in formulating the requested opinion.
3. Request an opinion from an appropriate VA physician as to the etiology of the Veteran’s right eye condition, to include corneal scar, right eye dryness, and reduced vision.  The physician should review the electronic records contained in VBMS and the Virtual VA system, including a copy of this remand.  
After reviewing the relevant evidence of record, the physician should provide an opinion as to whether it had its onset during service or was otherwise causally or etiologically related to service, to specifically include the in-service injury, as noted in the July 1980 service treatment record in which the Veteran suffered first and second degree burns to his body, areas of the face, and eyes from a car radiator explosion, as well as the April 1979 welding flash burn to his eyes. 
The examiner should address the Veteran’s contentions as to continuity of symptoms since service and that he self-medicated his symptoms during and service.
A complete rationale should accompany any opinion provided.
(Continued on the next page)
In addressing the above, the clinician must consider and discuss all pertinent medical and other objective evidence, as well as all lay assertions, and should not be based solely on the lack of documentation of sufficient disability or complaints in the STRs or post-service.
Jonathan Hager
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Sarah Campbell, Associate Counsel

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