HYPERTENSION

E. BLOWERS · 2022 · Case ID: 22006095

MIXED

Summary

The Veteran, an Army Veteran who served from October 1966 to October 1969, appeals the denial of service connection for hypertension, bilateral open-angle glaucoma, and blindness. The Veteran claimed these conditions were related to his service-connected type II diabetes mellitus, diabetic retinopathy, and cataracts, or other trauma and stressor-related disorders. The Board denied service connection for hypertension, finding no medical nexus to service-connected disabilities, as the Veteran's hypertension was diagnosed post-service and the VA examiner opined it was less likely than not related to service or aggravated by service-connected conditions. Similarly, service connection for bilateral open-angle glaucoma was denied due to a lack of medical nexus, with the VA examiner attributing it to hereditary or idiopathic etiology rather than service-connected diabetes or cataracts. For blindness, the Board acknowledged the Veteran's legal blindness and service-connected conditions but found no medical nexus linking blindness to service-connected diabetes, cataracts, or glaucoma, as the VA examiner opined it was less likely than not due to diabetes and not aggravated by cataracts. The Board denied direct service connection for all three conditions due to lack of in-service diagnosis or continuity of symptomatology. The Board considered the doctrine of reasonable doubt but found the evidence weighed against the claims. However, the claims for separate disability ratings for diabetic retinopathy and cataracts were remanded for clarification on the severity of visual impairment solely due to these service-connected conditions.

Rationale

No medical nexus between hypertension and service-connected disabilities.; VA examiner opined less likely than not related to service-connected conditions.; No evidence of hypertension during service or continuity of symptomatology.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

18-02 775

Full Decision Text

Citation Nr: 22006095
Decision Date: 02/03/22 Archive Date: 02/03/22

DOCKET NO. 18-02 775
DATE: February 3, 2022

ORDER

Entitlement to service connection for hypertension associated with type II diabetes mellitus with diabetic retinopathy and cataracts or other specified trauma and stressor related disorder is denied.

Entitlement to service connection for bilateral open-angle glaucoma is denied.

Entitlement to service connection for blindness is denied.

REMANDED

Entitlement to a separate and compensable disability rating for diabetic retinopathy (currently rated as a noncompensable disability associated with type II diabetes mellitus with diabetic retinopathy and cataracts) is remanded.

Entitlement to a separate and compensable disability rating for cataracts (currently rated as a noncompensable disability associated with type II diabetes mellitus with diabetic retinopathy and cataracts) is remanded.

FINDINGS OF FACT

1. The Veteran's hypertension is not secondary to a service-connected disability and is not otherwise related to an in-service injury or disease.

2. The Veteran's bilateral open-angle glaucoma is not secondary to a service connected disability and is not otherwise related to an in-service injury or disease.

3. The Veteran's blindness is not secondary to a service-connected disability and is not otherwise related to an in-service injury or disease.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for hypertension due to service or associated with a service-connected disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for entitlement to service connection for bilateral open-angle glaucoma due to service or due to a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for blindness due to service or due to a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from October 1966 until his honorable discharge in October 1969.

This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c).

These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2014 and October 2015 rating decisions by the Decatur, Georgia Regional Office (RO) of the United States Department of Veterans Affairs (VA).

In May 2019 and April 2021, the Board remanded this case to the RO for further development. The most recent April 2021 Board remand directed the RO to obtain updated treatment records not already in the file pertaining to treatment for the Veteran's cataracts, if any; obtain an addendum nexus opinion from an appropriate clinician regarding the Veteran's hypertension; and obtain an addendum nexus opinion from an appropriate clinician regarding the Veteran's bilateral open-angle glaucoma and blindness.

The Board notes that the Veteran has been granted total disability rating based on individual unemployability (TDIU) since October 1, 2014. See November 2020 Rating Decision.

The Board also notes that in January 2021, the Board received notification that the Veteran's attorney requested to withdraw from representation under 38 C.F.R. § 20.608. See January 21, 2021 correspondence (faxed on January 26, 2021 and received via mail on February 10, 2021).

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009)
for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of the disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995).

1. Entitlement to service connection for hypertension associated with type II diabetes mellitus with diabetic retinopathy and cataracts or other specified trauma and stressor related disorder

The Veteran asserts that his hypertension is related to his service-connected type II diabetes mellitus with diabetic retinopathy and cataracts and/or other specified trauma and stressor related disorder.

The Board notes that the evidence of record demonstrates that the Veteran has had hypertension since the 1980s and a current disability is not in dispute. Furthermore, the Veteran is service connected for type II diabetes mellitus with diabetic retinopathy and cataracts, and also service connected for other specified trauma and stressor related disorder. Therefore, the question for the Board is if the Veteran's hypertension is at least as likely as not caused by or aggravated beyond its natural progression by the Veteran's service-connected disabilities.

The Board finds that there is not medical nexus evidence establishing a connection between the Veteran's service-connected disabilities and the current disability. The Veteran was afforded a VA examination in June 2021. The June 2021 VA examiner opined that the Veteran's hypertension is less likely than not (less than 50 percent probability) proximately due to, or the result of, or aggravated beyond its natural progression by, the Veteran's service-connected disabilities. See June 2021 VA examination, p. 3. See also July 2021 VA examination (addendum), pp. 2-3.

The June 2021 VA examiner explained that hypertension is essential or primary, not secondary; and that essential hypertension (also called primary hypertension, or idiopathic hypertension) is the form of hypertension that, by definition, has no identifiable secondary cause, that affects 85 percent of those with high blood pressure, that tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors, and that the prevalence of essential hypertension increases with age and weight gain. The June 2021 VA examiner concluded by noting that the Veteran's blood pressure has also been maintained by medications.

The July 2021 VA examiner explained that none of the Veteran's service-connected disabilities, other than type II diabetes mellitus, are known to cause or aggravate beyond the natural progression hypertension. The July 2021 VA examiner notes that the Veteran has no evidence of diabetic nephropathy, and at the time of the Veteran's diagnosis of type II diabetes mellitus (approximately 2012), there was no evidence of renal dysfunction. The July 2021 VA examiner explains that hypertension can only be attributed to type II diabetes mellitus if it arises after
the prevalence of essential hypertension increases with age and weight gain. The June 2021 VA examiner concluded by noting that the Veteran's blood pressure has also been maintained by medications.

The July 2021 VA examiner explained that none of the Veteran's service-connected disabilities, other than type II diabetes mellitus, are known to cause or aggravate beyond the natural progression hypertension. The July 2021 VA examiner notes that the Veteran has no evidence of diabetic nephropathy, and at the time of the Veteran's diagnosis of type II diabetes mellitus (approximately 2012), there was no evidence of renal dysfunction. The July 2021 VA examiner explains that hypertension can only be attributed to type II diabetes mellitus if it arises after the onset of the type II diabetes mellitus, and there is associated diabetic nephropathy, and that the aggravation of hypertension can only be attributed to type II diabetes mellitus in the face of diabetic nephropathy. The examiner explained that an article noted a possible association between psychiatric disabilities but did not establish cause or aggravation. See July 2021 VA examination, p. 2. Accordingly, entitlement to service connection on a secondary basis for hypertension is denied.

As to direct service connection under 38 C.F.R. § 3.303, the Veteran does not claim, and the record does not show, that his hypertension is directly due to his active military service. In this regard, a review of the record on appeal does not show the Veteran being diagnosed with hypertension while on active duty. See 38 C.F.R. § 3.303(a). Likewise, the record does not show the Veteran had a problem with high blood pressure in and since service because the record does not reflect him being diagnosed with hypertension until the 1980s; approximately 10 20 years after service. See 38 C.F.R. § 3.303(b). Finally, the July 2021 VA examiner opined that the hypertension is less likely than not (less than 50 percent probability) due to active service (including herbicide agent exposure) because there was no evidence of hypertension during service, the Veteran's separation examination noted a blood pressure of 126/82, and herbicide agents have not been shown as a cause for hypertension. See July 2021 VA Examination (Addendum), p. 2. Accordingly, entitlement to service connection for hypertension is denied.

In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the significant weight of the probative evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

2. Entitlement to service connection for bilateral open-angle glaucoma

The Veteran asserts that glaucoma is related to his service-connected type II diabetes mellitus, cataracts, and/or diabetic retinopathy.

The Board notes that there is a current disability of bilateral open-angle glaucoma and that the Veteran is currently service-connected for type II diabetes mellitus, cataracts, and diabetic retinopathy. Therefore, the question for the Board is if there is medical nexus evidence establishing a connection between the Veteran's service connected disability and the current disability.

The Board finds that there is not medical nexus evidence establishing a connection between the Veteran's service-connected disability and the current disability. The RO obtained VA addendum opinion(s) in November 2021. The November 2021 VA examiner opined that the Veteran's bilateral open angle glaucoma was less likely than not (less than 50 percent probability) proximately due to, or the result of, a service-connected disability, or aggravated beyond its natural progression by the Veteran's service-connected diabetic retinopathy and/or cataracts because there is no evidence to support aggravation beyond natural progression and chronic open angle type glaucoma is the neovascular type of glaucoma, which would not be aggravated by type II diabetes mellitus. Furthermore, the Veteran's bilateral open angle glaucoma is not the type that would be aggravated by age related cataracts. The November 2021 VA examiner explained that because the Veteran's bilateral glaucoma was the open angle type of glaucoma, rather than neovascular glaucoma, there is no nexus between the Veteran's service-connected disabilities (including age-related cataracts) and his bilateral open angle glaucoma. Accordingly, entitlement to service connection on a secondary basis for bilateral open-angle glaucoma is denied.

As to direct service connection under 38 C.F.R. § 3.303, the Veteran does not claim, and the record does not show that his bilateral open angle glaucoma is directly due to his military service. In this regard, a review of the record on appeal
age related cataracts. The November 2021 VA examiner explained that because the Veteran's bilateral glaucoma was the open angle type of glaucoma, rather than neovascular glaucoma, there is no nexus between the Veteran's service-connected disabilities (including age-related cataracts) and his bilateral open angle glaucoma. Accordingly, entitlement to service connection on a secondary basis for bilateral open-angle glaucoma is denied.

As to direct service connection under 38 C.F.R. § 3.303, the Veteran does not claim, and the record does not show that his bilateral open angle glaucoma is directly due to his military service. In this regard, a review of the record on appeal does not show the Veteran being diagnosed with bilateral open angle glaucoma while on active duty. See 38 C.F.R. § 3.303(a). Likewise, the record does not show the Veteran had a problem with bilateral open angle glaucoma in and since service because the record does not reflect him being diagnosed with glaucoma until 1995; over 15 years after service. See 38 C.F.R. § 3.303(b). Finally, the November 2021 VA examiner opined that the Veteran's bilateral open angle glaucoma is most likely from a hereditary or idiopathic etiology. Accordingly, entitlement to service connection for bilateral open angle glaucoma is denied.

3. Entitlement to service connection for blindness

The Veteran asserts that blindness is related to his service-connected type II diabetes mellitus, cataracts, and/or diabetic retinopathy.

As a preliminary matter, the Board notes that there is no dispute that the Veteran is service connected for type II diabetes mellitus, cataracts, and diabetic retinopathy. Furthermore, affording the Veteran the benefit of the doubt, the Board finds that there is evidence of a current disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran's VA treatment records reflect notes documenting "legal blindness." Therefore, the question for the Board is if there is medical nexus evidence establishing a connection between the Veteran's service connected disability and the current disability.

Third, the Board finds that there is not medical nexus evidence establishing a connection between the Veteran's service-connected disability and the current disability. The RO obtained a nexus opinion from a VA examiner in November 2021. The November 2021 VA examiner opined that the Veteran's blindness is at least as likely as not (50 percent probability or greater) due to, or aggravated beyond its natural progression by, the Veteran's (nonservice-connected) bilateral chronic open angle glaucoma, and is less likely than not (less than 50 percent probability) due to his type II diabetes mellitus, diabetic retinopathy, and/or cataracts. The November 2021 VA examiner explained that type II diabetes mellitus causes a neovascular type of glaucoma from proliferative diabetic retinopathy, which the Veteran does not have, and that there is no basis for a nexus between the Veteran's natural age-related cataracts and chronic open-angle glaucoma. Accordingly, entitlement to service connection on a secondary basis for blindness is denied.

As to direct service connection under 38 C.F.R. § 3.303, the Veteran does not claim, and the record does not show, that any blindness is directly due to military service. In this regard, a review of the record on appeal does not show the Veteran being diagnosed with blindness while on active duty. See 38 C.F.R. § 3.303(a). Likewise, the record does not show that the Veteran had a problem with blindness in and since service because the record does not reflect him being diagnosed with blindness for over 15 years after service. See 38 C.F.R. § 3.303(b). Accordingly, entitlement to service connection for blindness is denied.

REASONS FOR REMAND

1. Entitlement to a separate and compensable disability rating for diabetic retinopathy (currently rated as a noncompensable disability associated with type II diabetes mellitus with diabetic retinopathy and catar
does not reflect him being diagnosed with blindness for over 15 years after service. See 38 C.F.R. § 3.303(b). Accordingly, entitlement to service connection for blindness is denied.

REASONS FOR REMAND

2. Entitlement to a separate and compensable disability rating for cataracts (currently rated as a noncompensable disability associated with type II diabetes mellitus with diabetic retinopathy and cataracts) is remanded.

Due to the similar dispositions for the above issues on appeal, the Board will address them in a common discussion below.

Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Included within the Veteran's November 2021 VA examination addendum, the VA examiner noted that the Veteran's visual acuity in his right eye is due to his nonservice-connected glaucoma. However, the November 2021 VA examiner noted that the Veteran's visual acuity in his left eye is due to the Veteran's service connected cataract and nonservice-connected glaucoma, resulting in a reduced acuity.

Significantly, the November 2021 VA examiner did not provide what portion of the diminished visual acuity is due to each disability, or if it was impossible to determine.

Therefore, a remand for clarification is required.

The aforementioned matters are REMANDED for the following action:

1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected diabetic retinopathy and cataracts (exclusive of his other eye disabilities). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria.

The examiner must opine on the level of severity of diminished visual acuity and visual fields (if any) caused only by his service-connected diabetic retinopathy and cataracts.

If the examiner is unable to opine on the level of severity of impairment(s) due to only his service-connected diabetic retinopathy and cataracts, the examiner must also note if the inability to opine is due to a lack of personal knowledge, or lack of knowledge within the medical community.

E. BLOWERS

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board G. Deemer, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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