Citation Nr: 18160335
Decision Date: 12/26/18	Archive Date: 12/26/18

DOCKET NO. 16-42 156
DATE:	December 26, 2018
ORDER
New and material evidence having been submitted, the claim for entitlement to service connection for an acquired psychiatric disorder, to include diagnosed depression and posttraumatic stress disorder (PTSD), is reopened.
Entitlement to service connection for gout is denied.
Entitlement to an increased evaluation in excess of 10 percent prior to December 10, 2014 and in excess of 20 percent thereafter for service-connected residuals of left eye injury is denied.
REMANDED
Entitlement to service connection for an acquired psychiatric disorder, to include diagnosed depression and PTSD, is remanded.
Entitlement to service connection for back pain and atrophy in both limbs with numbness and tingling is remanded.
Entitlement to service connection for right arm stiffness, tingling, and numbness is remanded.
Entitlement to service connection for left arm stiffness, tingling, and numbness is remanded.
 Entitlement to service connection for a disability characterized as atrophy, muscular limbs is remanded.
Entitlement to an increased evaluation in excess of 20 percent for service-connected residuals of right shoulder sprain is remanded.
Entitlement to an increased evaluation in excess of 10 percent for service-connected chondromalacia left knee is remanded.
Entitlement to an increased evaluation in excess of 10 percent for service-connected chondromalacia right knee is remanded.
Entitlement to an increased evaluation in excess of 10 percent for esophageal spasms is remanded.
FINDINGS OF FACT
1. The Veteran filed a claim for service connection for PTSD and depression in December 2008.  In a January 2010 rating decision, the RO denied service connection. The Veteran did not submit any additional evidence or an intention to appeal this decision and it was finalized one year later in January 2011.  The Veteran then filed the current claim to reopen in December 2014.
2. The evidence added to the record since the final January 2010 rating decision is not cumulative or redundant of the evidence of record on file at the time and raises a reasonable possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disorder.
3. The probative medical evidence of record does not show that the Veteran’s currently diagnosed gout was caused by or incurred in military service, nor was it shown to have developed within one year of leaving military service.
4. Prior to December 10, 2014, the Veteran’s left eye disability was manifested by a diagnosis of a left eye macular scar due to a left eye injury with a loss of vision due a visual field defect with an average contraction of 49.75 degrees that had a visual equivalent of 20/50 and no findings of visual acuity loss, diplopia, disfigurement, or incapacitating episodes.
5. From December 10, 2014, the Veteran’s left eye disability was manifested by a diagnosis of a left eye macular scar due to a left eye injury with a loss of vision due to a visual acuity loss with corrected distance vision of 20/50; a visual field defect with an average contraction of 49.75 degrees that had a visual equivalent of 20/50; and no findings of visual acuity loss, diplopia, disfigurement, or incapacitating episodes.
CONCLUSIONS OF LAW
1. New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, to include diagnosed depression and PTSD.  38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017).
2. The criteria for establishing service connection for gout is the result of military service are not met.  38 U.S.C. §§ 1110, 1131, 5103, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017).
3. The criteria for a disability rating in excess of 10 percent prior to December 10, 2014 and in excess of 20 percent thereafter for the Veteran’s service-connected residuals of left eye injury are not met.  38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.79, Diagnostic Codes 6066 and 6080 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran had active service from September 1985 to January 2002.
This matter comes before the Board of Veterans’ Appeals (Board) from December 2013 and April 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).
New and Material
Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed.  38 U.S.C. §§ 7104 (b), 7105(c).  The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 
New evidence means existing evidence not previously submitted to agency decisionmakers.  Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156 (a).
The determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material.  See Shade v. Shinseki, 24 Vet. App. 110 (2010).  New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion.  Id. 
For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed.  Justus v. Principi, 3 Vet. App. 510, 513 (1992).
In making all determinations, the Board must fully consider the lay assertions of record.  A layperson is competent to report on the onset and recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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.  Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1377 (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”).
The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107 (a).  See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). The Board shall consider all information and lay and medical evidence of record.  38 U.S.C. § 5107 (b).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant.  Id; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
The Veteran filed a claim for service connection for PTSD and depression in December 2008.  In a January 2010 rating decision, the RO denied service connection.  The Veteran did not submit any additional evidence or an intention to appeal this decision and it was finalized one year later in January 2011.  The Veteran then filed a claim to reopen service connection for depression in December 2014.  In an April 2015 rating decision, the RO denied reopening the Veteran’s claim for a failure to submit new and material evidence.
The January 2010 rating decision denied the claim on the basis that there was no showing of any current disability.  The Veteran was notified of the decision on January 2010.  He had until January 2011, to submit additional evidence or an intention to appeal.  The Veteran did not submit any new evidence or claim until December 2014, almost 4 years after the deadline.  Therefore, the January 2010 rating decision became final. 
Since the January 2010 rating decision was finalized, additional evidence has been associate with the claims file, to include records showing treatment and a diagnosis of both PTSD and depression from 2012 to present.  These treatment records are new because they had not been previously considered and were not associated with the claims file until 2013.  They are also material because they address the issue of the existence of a current disability with the potential for a nexus, as the Veteran’s treating physicians have described the Veteran’s disorder in terms of stemming from his military service.  This at the very least meets the minimum threshold requirements under Shade, 24 Vet. App. at 110 for a finding of new and material evidence.  As new and material evidence has been received, the claim of entitlement to service connection for an acquired psychiatric disorder is reopened.
Service Connection
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 the active military service or, if pre-existing such service, was aggravated by service.  38 U.S.C. §§ 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). 
Service connection may be established for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303 (d).
Generally, service connection requires evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury.  38 C.F.R. § 3.303 (a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).
Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 C.F.R. § 3.310 (a).
Certain chronic diseases, such as arthritis may be presumed to have been incurred in service if manifested to a compensable degree within one year after discharge from service.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a).
With chronic diseases shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time.  When the disease entity is established, there is no requirement of an evidentiary showing of continuity.  If the condition noted during service (or in the presumptive period) is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned, then generally a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303 (b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that as an alternative to the nexus requirement, service connection for a chronic disease listed under 3.309(a) may be established through a showing of continuity of symptomatology since service).
The Veteran contends that his currently diagnosed gout is the result of military service. 
A review of the Veteran’s service treatment records fails to reveal any discussion of complaints of gout or any arthritic or swelling problems in his toes. 
A review of the Veteran’s post-service treatment records shows that he has been treated for gout during the period of appeals since March 2012, when he was diagnosed with gouty arthritis in his left toes.  However, there has been no discussion of an etiology related to military service.
Having reviewed the complete record, the Board finds that service connection for gout is not warranted.  It is noted that the Veteran does have a current disability, however, there is no indication of any in-service event, injury or disease upon which to base direct service connection.  Here, the Veteran’s service treatment records do not show that he was treated for or diagnosed to have any complaints of gout.  This is despite the fact that the Veteran was seen on numerous occasions for other ailments, including various musculoskeletal injuries.  Therefore, due to the lack of a substantiated in-service event, injury, or disease, the Veteran’s claim on a direct basis fails, and the issue of nexus never materializes.
The Board also notes that the Veteran’s medical records do not show that his gout was manifested near in time to service, as the first evidence of record of a diagnosis is in 2012, approximately 10 years after active service.   
The only other statements asserting a relationship to military service for the current diagnosed gout are the Veteran’s own lay statements.  He, as a lay person, is competent to report an observable symptom.  See Layno, 6 Vet. App. at 467-69 (1994) (finding that the Veteran as a lay person is competent to report information of which he has personal knowledge, i.e., information that he can gather through his senses).  However, in this case, the question of whether the Veteran’s gout is related to military service is a complex medical question, not capable of lay observation.  See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (discussing that unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Falzone v. Brown, 8 Vet. App. at 405 (finding that a lay person is competent to testify to pain and visible flatness of his feet). 
Indeed, appropriate expertise is required to determine whether the Veteran’s gout is the result of military service.  In this case, the record is silent for any evidence to suggest that the Veteran has the appropriate training, experience, or expertise to render such findings.  See 38 C.F.R. § 3.159 (a)(1) (2017) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions).  Thus, while the Veteran is competent to report what he experiences, he is not competent to ascertain the etiology of his gout, as such is not readily subject to lay observation.  See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno, 6 Vet. App. at 465.  To the extent that the Veteran has suggested medical authority indicating a link between these conditions, the record is silent for any such support.  Thus, there is no probative evidence of any relationship between the Veteran’s military service and his claimed gout. 
Accordingly, the Board finds that service connection for gout 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 claim, that doctrine is not applicable.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53.
Increased Rating
Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017).  The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service.  The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations.  38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017).
In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  However, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods.
Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.
The Veteran’s service-connected left eye disability is rated as 10 percent disabling prior to December 10, 2014 and 20 percent disabling thereafter.  38 C.F.R. § 4.79, Diagnostic Codes and 6066 (visual acuity) and 6080 (visual field defect). 
Visual impairment is rated based on the consideration of three factors: 1) impairment of visual acuity (excluding developmental errors of refraction), 2) visual field, and 3) muscle function.  38 C.F.R. § 4.75 (a).  However, examinations of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function.  38 C.F.R. § 4.75 (b).
Central visual acuity is to be evaluated based on corrected distance vision with central fixation, even if a central scotoma is present.  However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, the visual acuity of the poorer eye is to be evaluated using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity.  38 C.F.R. § 4.76 (b). 
When both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the evaluation is determined by separately evaluating the visual acuity and visual field defect (expressed as a level of visual acuity) and combined under the provisions of 38 C.F.R. § 4.25.  38 C.F.R. § 4.77(c).
Under 38 C.F.R. § 4.79 Diagnostic Code 6066, for visual acuity in one eye of 25/50 and the other eye of 20/40, a 10 percent evaluation is warranted.  For visual acuity in one eye 10/200 (3/60) or better, the minimum 30 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 20/40 (6/12). 38 C.F.R. § 4.79.  A 40 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 20/50 (6/15).  Id.  A 50 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 20/70 (6/21).  Id.  A 60 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 20/100 (6/30).  Id.  A 70 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 20/200 (6/60).  Id.  An 80 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 15/200 (4.5/60).  Id.  The maximum 90 percent disability rating is warranted for vision in one eye 10/200 (3/60) and in the other eye 10/200 (3/60).  Id.
Lastly, the maximum evaluation for visual impairment of one service connected eye must not exceed 30 percent unless there is anatomical loss of the eye.  38 C.F.R. § 4.75 (d).  The evaluation for visual impairment may be combined with evaluations for other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under Diagnostic Code 7800).  Id. 
Loss of vision can also be rated based on impairment of the field of vision.  In this regard, under 38 C.F.R. § 4.76a , Table III, the normal visual field extent at the 8 principal meridians totals 500 degrees.  The normal for the 8 principal meridians are as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally.  Id.  The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45 degree principal meridians.  Id. 
Under Diagnostic Code 6080, a 10 percent rating is assigned for a unilateral scotoma; with remaining field of 46 to 60 degrees bilaterally or unilaterally; with remaining field of 31 to 45 degrees unilaterally; with remaining field of 16 to 30 degrees unilaterally; loss of superior half of visual field bilaterally or unilaterally; loss of interior half of visual field unilaterally; loss of nasal half of visual field bilaterally or unilaterally; and loss of temporal half of visual field unilaterally. 
A 30 percent rating is assigned for remaining field of 31 to 45 degrees unilaterally; concentric contraction of visual field unilaterally; loss of temporal half of visual field bilaterally; and homonymous hemianopia visual filed defects.  Id.
A 50 percent rating is assigned for remaining field of 16 to 30 degrees bilaterally.  Id. 
A 70 percent rating is assigned for remaining field of 6 to 15 degrees bilaterally.  Id.
A 100 percent rating is assigned for concentric contraction of visual field with remaining field of 5 degrees.  Id.
For rating on the basis of muscle impairment, the regulations provide that evaluations are based on the degree of diplopia and the equivalent visual acuity, and that the rating for diplopia is applicable to only one eye.  38 C.F.R. § 4.79, Diagnostic Code 6090.  Separate ratings are not permitted for both diplopia and decreased visual acuity or field of vision in the same eye.  Additionally, the regulations allow for an adjustment to the best-corrected visual acuity to account for diplopia.  38 C.F.R. § 4.78 (b)(3) (when diplopia exists in two individual and separate areas of the same eye, the equivalent visual acuity is taken one step worse, but no worse than 5/200).  Under the regulations, if diplopia manifests centrally at 20 degrees, it is rated equivalent to a visual acuity of 5/200.  38 C.F.R. § 4.79, Diagnostic Code 6090(a).  This is the highest equivalent visual acuity permitted.
The Veteran can also be evaluated under Diagnostic Code 7800 for disfigurement, although the medical evidence of record does not reveal that this is applicable under the facts of this particular case. 
Last, the Rating Schedule affords higher evaluations based upon the presence of incapacitating episodes.  The Rating Schedule defines an incapacitating episode as a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider.  38 C.F.R. § 4.79, General Rating Formula for Diagnostic Codes 6000 through 6009, Note.
In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrent symptoms.  See Layno, 6 Vet. App. at 470 (a Veteran is competent to report on that of which he or she has personal knowledge). 
The Veteran contends that his service-connected left eye disability is worse than reflected by his current evaluations of 10 percent prior to December 10, 2014 and 20 percent thereafter.  In this regard, the Veteran has alleged that he has great difficulty completing tasks of daily living due to his decreased vision.
A review of the Veteran’s outpatient treatment records reveals that he has been followed for treatment of his left eye disability throughout the pendency of this appeal.
The Veteran was provided with a VA examination in December 2013. At this examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with macular scar of the left eye from a left eye injury in 1992.  The Veteran complained of symptoms that have worsened since the initial injury.  The eye examination showed no evidence of pterygium, diplopia, or glaucoma.  Scarring was noted, but found to be non-disfiguring.  No incapacitation resulting in doctor ordered bed rest was noted.  The Veteran’s distance vision was 20/40 bilaterally (uncorrected) and 20/40 bilaterally (corrected).  The Veteran’s near vision was 20/70 left and 20/40 right (uncorrected) and 20/40 bilaterally (corrected).  There was no difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision being worse.  A visual field defect was noted.  The Veteran’s Goldman Perimeter testing revealed for the left eye, 72 temporally; 73 down temporally; 51 down; 41 down nasally; 54 nasally; 41 up nasally; 31 up; and 35 up temporally.  It was noted that the Veteran’s condition presents difficulty with field of vision, particularly at night with driving and object location.
Outpatient treatment records from the Veteran’s private provider in March 2015 showed that the Veteran complained of blurry vision all the time and blind spots.  The Veteran’s distance vision was 20/100 left and 20/60 right (uncorrected) and 20/50 left and 20/30 right (corrected).  A posttraumatic macular scar was noted on the left eye.
The Veteran was provided with an additional VA examination in March 2015. Upon a review of the claims file, subjective interview, and objective testing the Veteran was diagnosed with a macular scar of the left eye.  The Veteran complained of symptoms that have worsened since the initial injury.  The eye examination showed no evidence of pterygium, diplopia, or glaucoma.  Scarring was noted, but found to be non-disfiguring.  No incapacitation resulting in doctor ordered bed rest was noted.  The Veteran’s distance vision was 20/200 left and 20/70 right (uncorrected) and 20/50 left and 20/40 right (corrected).  The Veteran’s near vision was 20/100 left and 20/70 right (uncorrected) and 20/40 bilaterally (corrected).  There was no difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision being worse.  A visual field defect was noted.  The Veteran’s Goldman Perimeter testing revealed for the left eye, 85 temporally; 62 down temporally; 52 down; 41 down nasally; 52 nasally; 35 up nasally; 29 up; and 42 up temporally. The Veteran’s condition was found not to interfere with his occupational functioning.
Based on the above, the Board finds that the Veteran’s left eye disability only warrants an evaluation of 10 percent prior to December 10, 2014 and a 20 percent evaluation thereafter throughout the period of appeals.  
Prior to December 10, 2014
In regard to the Veteran’s visual acuity during this period, findings have shown his corrected distance vision to warrant, at most, a 0 percent evaluation.  This is because, prior to December 10, 2014, the Veteran’s visual acuity was only shown to be 20/40 for corrected distance.
In regard to the Veteran’s visual field, the Board finds that, at most, the Veteran would be entitled to a 10 percent evaluation under the rating criteria for a remaining visual field of 49.75 degrees.  The remaining visual field was calculated by adding up the measurements for the 8 principle meridians, 72 temporally; 73 down temporally; 51 down; 41 down nasally; 54 nasally; 41 up nasally; 31 up; and 35 up temporally, as shown on the Veteran’s November 2013 VA examination.  This added up to a total of 398 degrees.  When divided by the 8 principle meridians, this resulted in an average remaining visual field of 49.75 degrees.  When applied to the rating criteria, an evaluation of 10 percent results.  
As there was no finding of diplopia during this time period, there would no separate evaluations available for a finding of any eye muscular defect.
As the only compensable defect shown during this time period was the Veteran’s visual field defect as discussed above, only a 10 percent for that defect is warranted.  Therefore, for the period prior to December 10, 2014, the Veteran is only entitled to a 10 percent evaluation. 
From December 10, 2014
In regard to the Veteran’s visual acuity during this time period, findings have shown his corrected distance vision to warrant, at most, a 10 percent evaluation.  This is because, as shown in the March 2015 private examination and March 2015 VA examination, the Veteran’s corrected distance visual acuity for the left eye was 20/50.
All other visual acuity testing for corrected distance vision during this time period showed the Veteran’s acuity to be within normal limits for the right eye. Therefore, based on the above, 10 percent is the highest evaluation that would be warranted throughout the period of appeals taking acuity into consideration.
In regard to the Veteran’s visual field, the Board finds that, at most, the Veteran would be entitled to a 10 percent evaluation under the rating criteria for a remaining visual field of 49.75 degrees.  The remaining visual field was calculated by adding up the measurements for the 8 principle meridians, 72 temporally; 73 down temporally; 51 down; 41 down nasally; 54 nasally; 41 up nasally; 31 up; and 35 up temporally, as shown on the Veteran’s March 2015 VA examination.  This added up to a total of 398 degrees.  When divided by the 8 principle meridians, this resulted in an average remaining visual field of 49.75 degrees.  When applied to the rating criteria, an evaluation of 10 percent results.  
As there was no finding of diplopia during this time period, there would no separate evaluations available for a finding of any eye muscular defect.
Because the Veteran has both findings of visual acuity defect and a visual field defect, special consideration must be afforded.  To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, separately evaluate the visual acuity and visual field defect (expressed as a level of visual acuity), and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77 (c).  As such, when combining the 10 percent for the Veteran’s visual acuity with 10 percent for the Veteran’s visual field, a combined evaluation of 20 percent results.
The Board has considered whether staged ratings higher than 10 percent and 20 percent are warranted but finds that they are not, as the evidence, including the Veteran’s credible and probative statements, does not show that there are distinct periods of time where evaluations in excess of 10 percent and 20 percent are warranted.  The evidence of record does not warrant ratings in excess of those assigned for the Veteran’s left eye disability at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
As the preponderance of the evidence is against the Veteran’s claim for increased ratings in excess of the 10 percent granted prior to December 10, 2014 or the 20 percent previously awarded from December 10, 2014, the benefit-of-the-doubt doctrine is inapplicable and the claim must be denied.  38 U.S.C. § 5107.



REASONS FOR REMAND
1. Back, Bilateral Arms, Muscular Limbs
In a March 2018 rating decision, the Veteran claims for service connection for his back, bilateral arms, and the atrophy, muscular limbs was denied.  In a June 2018 notice of disagreement (NOD), the Veteran appealed this decision.  A review of the claims file does not show that the Veteran has been provided with a statement of the case (SOC) for these issues, despite having filed a timely appeal.
An unprocessed NOD shall be remanded, not referred, to the RO for issuance of an SOC.  Manlincon v. West, 12 Vet. App 238, 240-241.  Thus, these claims shall be remanded and have been added to the caption of the title page accordingly.
2. Acquired Psychiatric Disorder
Having reopened the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder, the Board finds that remand is necessary.
In this regard, it is noted that the Veteran has not previously been provided with a VA examination for this condition.  It is noted that the Veteran has current psychiatric diagnoses and evidence indicating a relationship to service.  As such, the Board finds that the minimum requirements for a VA examination have been met.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006).
3. Right Shoulder and Bilateral Knees
The Veteran has been previously provided with VA examinations for the right shoulder and bilateral knees in March 2015.
  In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities.  The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.”  The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59.
In this case, the examination forms used in the administration of the Veteran’s prior VA examinations appears to have used a format that did not contain any discussion of these presentations as appear to have been contemplated by the holding in Correia.  Accordingly, the Veteran should be afforded new VA examinations for the right shoulder and bilateral knees to comply with this case.
Additionally, this remand will also afford the RO the opportunity to ask the clinician who conducts the requested VA examination to apply a decision issued by the Court, Sharp v. Shulkin, 29 Vet. App. 26 (2017).  In Sharp, the Court noted that the VA’s Clinician’s Guide specifically advises examiners to try to procure information necessary to render an opinion regarding flares from Veterans.  The Court in Sharp found that the examination in question in that case to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of his conditions, failed to ascertain adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means.  Id.  The prior VA examinations discussed above did not reflect the considerations required by Sharp, and the instructions to the examiner below will request such consideration.
4. Esophageal Spasms
The Veteran was last afforded with a VA examination for his esophageal spasms in March 2015.  Since that time, the Veteran has complained of worsening symptoms for this condition.  As such, it is necessary to obtain a new examination in order to assess the current effects of the Veteran’s esophageal spasms.
As this case must be remanded for the foregoing reasons, any recent treatment records, including VA records, should also be obtained.  38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992).
The matters are REMANDED for the following action:
1. The RO should issue an SOC on the issues of entitlement to service connection for back, and bilateral arm disabilities, as well as, disability characterized as atrophy, muscular limbs. The RO should advise the Veteran of the need to timely file a substantive appeal to perfect appellate review.
2. Obtain and associate updated VA treatment records.
3. Thereafter, schedule the Veteran for a VA examination to determine whether it is as likely as not any current psychiatric disorder was incurred in service.  The record should be made available to the examiner. Any required testing should be performed and recorded.
The examiner should provide an opinion whether it is at least as likely as not (probability of 50 percent or more) that any current acquired psychiatric disorder had its onset in service or is otherwise related to an in-service disease or injury.  If PTSD is diagnosed, the stressor should be identified.  
A complete rationale for any opinions rendered should be provided.
4. The Veteran should also be scheduled for a VA examination to determine the nature, severity, and extent of his current pathology associated with his service-connected right shoulder and bilateral knees. The record, should be made available to the examiner. Any required testing should be performed and recorded.
The examiner should take into account any of the Veteran’s lay statements regarding the worsening of his condition.
To the extent possible, the examiner should conduct range of motion testing of these joints (expressed in degrees) in active motion, passive motion, weight-bearing and nonweight-bearing. The examiner should note the point at which pain begins in the range of motion and whether there is weakness, excess fatigability, and/or incoordination associated with the right shoulder and bilateral knees. 
The examiner should also describe the functional limitations resulting from the right shoulder and bilateral knees, to include during flare-ups. If flare-ups are not shown during the examination, the examiner should conduct efforts to obtain adequate information regarding the impairment resulting from flare-ups by alternative means, to include statements as to any such impairment by the Veteran himself.
A complete rationale for any opinions rendered should be provided.
5. The Veteran should also be scheduled for a VA examination to determine the nature, severity, and extent of his current pathology associated with his service-connected esophageal spasms. The record should be made available to the examiner. Any required testing should be performed and recorded. 
A complete rationale for any opinions rendered should be provided.
6. If any benefit sought on appeal remains denied, issue a Supplemental Statement of the Case before returning the case to the Board, if otherwise in order.

 
M. E. KILCOYNE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	R. Dodd, Counsel 

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