EYE IMPAIRMENT OF MUSCLES OF

Summary

The veteran served on active duty from December 1969 to November 1971. He appealed the denial of service connection for a left eye disorder, a lumbar spine disorder, an acquired psychiatric disorder (including PTSD), and hypertension. The Board denied all claims. For the left eye and lumbar spine disorders, the Board found that current diagnoses were not established, and the medical evidence did not support service connection. The veteran's lay statement about dust in his eyes and a general claim of injury were insufficient without specific medical evidence of a current disability. Regarding the acquired psychiatric disorder, the Board noted the veteran's lay statements about in-service stressors, including witnessing traumatic events, and acknowledged a favorable finding for a combat infantry badge. However, the Board found no current diagnosis of a psychiatric disorder, citing negative PTSD and depression screenings in clinical records and the February 2021 VA examination. The Board also noted the veteran's statement that another veteran suggested he apply for PTSD. For hypertension, the Board acknowledged a favorable finding of a current diagnosis but found no in-service incurrence or continuity of symptomatology, as service treatment records were negative for complaints or treatment, and his blood pressure was normal at separation. The presumptive service connection criteria were also not met due to the 49-year gap between separation and diagnosis. The Board found the veteran competent to report symptoms but not etiologies, giving greater weight to clinical findings over lay statements.

Rationale

No current diagnosis of left eye disorder; Lay statement insufficient without medical evidence

Full Decision Text

Citation Nr: A22011917
Decision Date: 06/24/22	Archive Date: 06/24/22

DOCKET NO. 220316-228645
DATE: June 24, 2022

ORDER

Service connection for a left eye injury is denied.

Service connection for lumbar spine disorder is denied.

Service connection for an acquired psychiatric disorder is denied.

Service connection for hypertension is denied.

FINDINGS OF FACT

1. A current left eye disorder has not been established.  

2. A current lumbar spine disorder has not been established .  

3. A current acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), has not been established.

4. Hypertension was not diagnosed in service, was not continuous since service, was not shown to a compensable degree within one year of service, and is not casually or etiologically related to service,

CONCLUSIONS OF LAW

1. A left eye disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2021).

2. A lumbar spine disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2021).

3. An acquired psychiatric disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2021).

4. Hypertension was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309 (2021).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from December 1969 to November 1971.

In August 2017, the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA), was signed into law. This law created a new framework for veterans dissatisfied with VA's decision on their claim to seek review. The AMA automatically applies to all claims for which VA issues notice of an initial decision on or after February 19, 2019. See 38 C.F.R. § 3.2400(a)(1).

In a March 2021 rating decision, the Agency of Original Jurisdiction (AOJ) denied the claims. In March 2022, the Veteran appealed this denial to the Board and requested a 90 day evidence submission.  

Service connection

Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). 

Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307.

Left Eye and Lumbar Spine Disorders

In a January 2021 statement, the Veteran contended that he was wounded while on his last mission and got dust in his eyes. However, he did not specify that he hurt his back or left eye in service.

Further, current diagnoses of left eye and lumbar spine disorders are not shown. Specifically, clinical records show treatment for hypertension, hearing loss, tinnitus, and an
 an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307.

Left Eye and Lumbar Spine Disorders

In a January 2021 statement, the Veteran contended that he was wounded while on his last mission and got dust in his eyes. However, he did not specify that he hurt his back or left eye in service.

Further, current diagnoses of left eye and lumbar spine disorders are not shown. Specifically, clinical records show treatment for hypertension, hearing loss, tinnitus, and an acquired psychiatric disorder. However, there is no mention of a left eye or lumbar spine disorder. Therefore, current diagnoses are not shown, and the medical evidence does not support the claims of service connection.  

The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board recognizes that the U.S. Court of Appeals for Veterans Claims (Court) has held that the presence of a chronic disability at any time during or immediately preceding the claims process can justify a grant of service connection, even where the most recent diagnosis is negative. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (holding the current disability requirement may be satisfied by evidence of the disability shortly before the claim is filed). The Board further recognizes that pain or other symptomatology, even without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018). In the present case, however, the Veteran has not established a current disability or any functional impairment of the left eye or lumbosacral spine, service connection is not warranted.  

Acquired Psychiatric Disorder

With specific regard to PTSD, three elements must be present: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997).

The Veteran contends that an acquired psychiatric disorder, to include PTSD, was incurred in service. In a January 2021 statement, he reported multiple in-service stressors, such as watching a helicopter catch on fire and seeing soldiers lose their limbs after stepping on claymore mines. 

As reflected in the March 2021 rating decision, the AOJ rendered a favorable finding that the Veteran received a combat infantry badge. Per applicable law, favorable findings are binding on the Board.

However, an acquired psychiatric disorder is not shown. Specifically, the Veteran underwent a February 2021 VA examination and was not diagnosed with any psychiatric disorder. Further, at the examination, the Veteran reported that he was approached by another veteran who told him to apply for service connection for PTSD.

Clinical records also showed that the Veteran was not diagnosed with an acquired psychiatric disorder. Specifically, in a September 2020 clinical record, PTSD and depression screenings were negative. Therefore, the first element of direct service connection is not met, and the medical evidence does not support the claim of service connection. 

Hypertension

As an initial matter, hypertension is a chronic disorder under 38 C.F.R. § 3.309. Therefore, both direct and presumptive service connection will be addressed. 

Turning to direct service connection, in the March 2021 rating decision, the AOJ rendered a favorable finding that the Veteran had been diagnosed with hypertension. Under applicable law, favorable findings are binding on the Board. Therefore, a current disorder is shown, and the first element of direct service connection is met.

As to an in-service incurrence, service treatment records are absent of complaints, diagnoses, or treatment of hypertension. Specifically, in an October 1970 service treatment records, the Veteran reported that he had never been treated for high blood pressure. Further, the Veteran's blood pressure at separation was within normal limits. Therefore, the second element of direct
3.309. Therefore, both direct and presumptive service connection will be addressed. 

Turning to direct service connection, in the March 2021 rating decision, the AOJ rendered a favorable finding that the Veteran had been diagnosed with hypertension. Under applicable law, favorable findings are binding on the Board. Therefore, a current disorder is shown, and the first element of direct service connection is met.

As to an in-service incurrence, service treatment records are absent of complaints, diagnoses, or treatment of hypertension. Specifically, in an October 1970 service treatment records, the Veteran reported that he had never been treated for high blood pressure. Further, the Veteran's blood pressure at separation was within normal limits. Therefore, the second element of direct service connection is not met, and the medical evidence does not support the claim of direct service connection. 

Turning to presumptive service connection, the medical evidence showed that the Veteran was discharged from service in 1971 but was not diagnosed with hypertension until 2020. As he was discharged in 1971 and symptoms of hypertension were not identified until 2020, 49 years later, the medical evidence does not support service connection on a chronic in service or continuity of symptomatology basis.

Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. Specifically, the Veteran separated from service in 1971 and was not diagnosed with hypertension until 2020. Therefore, this evidence does not support presumptive service connection on a "manifest within one-year from separation" basis, and the medical evidence does not support presumptive service connection is not supported by the medical evidence.

The Board has considered the Veteran's lay statements that these disorders began in service. He is competent to report symptoms because this requires only personal knowledge, as it comes to him through his senses; however, he is not competent to offer an opinion as to the etiologies of his current disorders due to the medical complexity of the matters involved.  

Such competent evidence has been provided by the medical personnel who have examined the Veteran during the appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to the lay statements. Therefore, the appeals are denied. 

Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

 

 

T.D. JONES

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Ragofsky, 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.