Citation Nr: 0006683 Decision Date: 03/13/00 Archive Date: 03/17/00 DOCKET NO. 98-07 987 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York THE ISSUES 1. Entitlement to service connection for an eye condition. 2. Entitlement to service connection for a dental condition for the purpose of obtaining VA outpatient dental treatment. 3. Entitlement to service connection for a disorder manifested by sterility. 4. Entitlement to a higher rating for peripheral neuropathy of the right lower extremity, status post total body radiation and stem cell transplant for non-Hodgkin's lymphoma (NHL), initially assigned a 10 percent evaluation, effective from June 1996. 5. Entitlement to a higher rating for peripheral neuropathy of the left lower extremity, status post total body radiation and stem cell transplant for NHL, initially assigned a 10 percent evaluation, effective from June 1996. 6. Entitlement to a higher rating for peripheral neuropathy of the right (major) upper extremity, status post total body radiation and stem cell transplant for NHL, initially assigned a 10 percent evaluation, effective from June 1996. 7. Entitlement to a higher rating for peripheral neuropathy of the left (minor) upper extremity, status post total body radiation and stem cell transplant for NHL, initially assigned a 10 percent evaluation, effective from June 1996. 8. Entitlement to a higher rating for low back and bilateral knee pain, initially assigned a 10 percent evaluation, effective from June 1996. 9. Entitlement to a higher rating for a disorder manifested by impaired diffusion capacity, initially assigned a 10 percent evaluation, effective from June 1996. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Richard V. Chamberlain, Counsel INTRODUCTION The veteran had active service from December 1965 to December 1968. This appeal comes to the Board of Veterans' Appeals (Board) from March 1997 and later RO rating decisions that denied the veteran's claims for service connection for an eye condition, a dental condition, and sterility as not well grounded; and that granted service connection for the conditions shown on the first page of this decision, and assigned 10 percent evaluations for each of these conditions, effective from June 1996. The issues of service connection for an eye condition; service connection for a dental condition for the purpose of obtaining VA outpatient dental treatment; and entitlement to a higher rating for low back and bilateral knee pain, initially assigned a 10 percent evaluation, effective from June 1996, will be addressed in the remand section of this decision. FINDINGS OF FACT 1. The veteran has not submitted competent (medical) evidence showing the presence of a disorder manifested by sterility. 2. The veteran has no more than mild incomplete paralysis of the sural nerves of the right and left upper extremities. 3. He has moderate incomplete paralysis of the sciatic nerves of the right and left lower extremities; more severe neurological deficits of the nerves of the lower extremities are not found. 4. The veteran's respiratory disability is manifested primarily by Forced Expiratory Volume in one second (FEV-1) of 91 percent predicted, a ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC) of 91 percent predicted, and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 61 percent predicted. 5. Other symptoms of a respiratory disorder, such as persistent cough at intervals throughout the day, considerable expectoration, considerable dyspnea on exercise, rales throughout the chest or other manifestations that produce moderately severe ventilatory impairment are not found. CONCLUSIONS OF LAW 1. The claim for service connection for a disorder manifested by sterility is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for ratings in excess of 10 percent, effective from September 1996, for peripheral neuropathy of the right and left upper extremities, status post total body radiation and stem cell transplant for NHL, are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.124a, Code 8516 (1999). 3. The criteria for higher ratings of 20 percent, effective from September 1996, for peripheral neuropathy of the right and left lower extremities, status post total body radiation and stem cell transplant for NHL, are met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.124a, Code 8520 (1999) 4. The criteria for a rating in excess of 10 percent, effective prior to October 7, 1996, for a disorder manifested by impaired diffusion capacity are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.97, Code 6600, effective prior to October 7, 1996. 5. The criteria for a 30 percent evaluation, effective from October 7, 1996, for a disorder manifested by impaired diffusion capacity are met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.97, Code 6600, effective as of October 7, 1996. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for a Disorder Manifested by Sterility The threshold question to be answered in this case is whether the veteran has presented evidence of a well-grounded claim for service connection for a disorder manifested by sterility; that is, evidence which shows that this claim is plausible, meritorious on its own, or capable of substantiation. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78 (1990). If he has not presented such a claim, his appeal must, as a matter of law, be denied, and there is no duty on the VA to assist him further in the development of the claim. Murphy at 81. "The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court")" has also stated that a claim must be accompanied by supporting evidence; an allegation is not enough. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In a claim of service connection, this generally means that evidence must be presented which in some fashion links a current disability to a period of military service, or as secondary to a disability which already has been service- connected. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1999); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). "In order for a claim to be well-grounded, there must be competent evidence of current disability (a medical diagnosis) ...; of incurrence or aggravation of a disease or injury in service (lay or medical testimony), ...; and of a nexus between the inservice injury or disease and the current disability (medical evidence)." Caluza v. Brown, 7 Vet. App. 498 (1995). A DD Form 214 shows the veteran had active service from December 1965 to December 1968, including one year of active duty in Vietnam. His service medical records do not show the presence of NHL. The post-service medical records do not show the presence of NHL until 1994, and these medical records reveal that this condition was in remission in 1995. An August 1997 RO rating decision granted service connection for residuals of NHL based on presumed exposure to agent orange while in service. 38 C.F.R. §§ 3.307(a)(6)(iii) and 3.309(e) (1999). A December 1997 RO rating decision reclassified this disability to the various service-connected disabilities listed on the first page of this decision. The service and post-service medical records do not show the presence of a disorder manifested by sterility. Private medical reports dated in the 1990's are to the effect that the veteran has various medical conditions due to NHL or its treatment, and a report dated in April 1997 from Charles F. Romano, M.D., notes that the veteran complained of sterility due to radiation and chemotherapy for his NHL. The objective medical evidence, however, does not confirm that he has a disorder manifested by sterility. A claim is not well grounded where there is no medical evidence showing the presence of the disability it issue. Caluza, 7 Vet. App. 498. While statements from the veteran are to the effect that he has a disorder manifested by sterility due to radiation and chemotherapy for NHL, this lay evidence is not sufficient to demonstrate the presence of the claimed disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The medical evidence shows that the veteran underwent various medical examinations in 1997 to determine the residuals of status post NHL, and the reports of these examinations and the other medical evidence of record do not demonstrate the presence of a disability manifested by sterility. In this case, there is no competent (medical) evidence showing the presence of a disorder manifested by sterility, and the veteran's claim for service connection for such a disorder, either based on incurrence in service or secondary to a service-connected disability, is not plausible. Hence, the claim is denied as not well grounded. II. Entitlement to Higher Ratings for Peripheral Neuropathy of the Right and Left Upper and Lower Extremities, Status Post Total Body Radiation and Stem Cell Transplant for NHL, Initially Assigned a 10 Percent Evaluation for Each Extremity, Effective from June 1996 VA and private medical reports show that the veteran was treated and evaluated for various disorders in the 1990's. The more salient medical reports with regard to the peripheral neuropathy of the right and left upper and lower extremities are discussed in the following paragraphs. The veteran underwent a VA medical examination in September 1996. The diagnosis was NHL, status post cell bone marrow transplant, in remission. In 1997, the veteran underwent various VA medical examinations to determine the nature and extent of the residuals of NHL or treatment therefor. At a neurological examination in September 1997, he complained of numbness, tingling sensation, and weakness of the lower extremities. Strength was normal in the upper extremities and difficulty to assess in the lower extremities due to giveaway weakness secondary to back pain. Deep tendon reflexes were hypoactive, but symmetrical with downgoing toes. Sensory examination showed decreased pinprick in stocking distribution in the lower extremities. Proprioception and vibration were slightly decreased distally in the lower extremities. The impression was peripheral neuropathy. The veteran underwent a VA joint examination in October 1997. He complained of progressive loss of sensation, more so in the lower extremities, with difficulty feeling where his feet were. He reported that as a result of the decreased sensation he had fallen a number of times. Sensory examination of the lower extremities revealed diminished sensation in a stocking distribution, bilaterally. He had poor discrimination of sharp/dull utilizing a safety pin in his feet and was fairly consistent in sharp/dull discrimination by the level of the mid calf. This was relatively symmetric. Proprioception appeared grossly intact at the toes and ankles, bilaterally. He had extremely poor 2-point discrimination in the lower extremities as well. Manual muscle testing in the lower extremities revealed break-away weakness that was somewhat inconsistent and ratcheting with overall strength at the knee extensors and flexors as well as ankle plantar flexors and dorsiflexors of approximately 4-. He had at least 3+ hip flexor and hip extensor and could rise from a medium seat height without push off utilizing slight forward position. Standing balance was fair static and poor dynamic. He had a negative straight leg raise to 60 degrees, bilaterally. The impression was apparent peripheral polyneuropathy affecting primarily sensory nerves at the present time. The veteran underwent EMG (electromyograph) studies of the upper and lower extremities at a VA medical facility in November 1997. Sural sensory distal latency was unobtainable, bilaterally. Bilateral tibial motor distal latencies were prolonged, and amplitudes and conduction velocities throughout the leg were decreased. The ulnar nerve sensory distal latencies of both upper extremities were prolonged. The impression was electrodiagnostic evidence of peripheral polyneuropathy. The veteran's claims for higher ratings for the peripheral neuropathy of the right and left upper and lower extremities are well grounded, meaning they are plausible. The Board finds that all relevant evidence has been obtained with regard to the claims and that no further assistance to the veteran is required to comply with VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). In general, disability evaluations are assigned by applying a schedule of ratings (rating schedule) which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155. Although the regulations require that, in evaluating a given disability, it be viewed in relation to its whole recorded history, 38 C.F.R. § 4.41, where entitlement to compensation already has been established, and an increase in the disability rating is at issue, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Also, where there is a question as to which of two 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 evidence indicates the veteran has polyneuropathy of the upper and lower extremities. The sural nerve of the upper extremities is the affected nerve, and the sciatic and sural nerves of the lower extremities are the affected nerves. Therefore, the Board will evaluate the severity of the polyneuropathy of the upper extremities under diagnostic code 8516 and the polyneuropathy of the lower extremities under diagnostic code 8520, rather than 8521, as the provisions of diagnostic code 8520 provide for higher ratings and separate evaluations for the impairment of the sciatic and sural nerves may not be assigned as they affect essentially similar functions. 38 C.F.R. § 4.14 (1999). A 10 percent evaluation is warranted for mild incomplete paralysis of the ulnar nerve of the major or minor upper extremity. A 20 percent evaluation is warranted for moderate incomplete paralysis of the ulnar nerve of the minor upper extremity. A 30 percent evaluation is warranted for moderate incomplete paralysis of the ulnar nerve of the major upper extremity. 38 C.F.R. § 4.124a, Codes 8516, 8616, 8716. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. Complete paralysis of the ulnar nerve is indicated when there is "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of right and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. A 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent evaluation requires moderate incomplete paralysis. A 40 percent evaluation requires moderately severe incomplete paralysis. A 60 percent rating requires severe incomplete paralysis. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. An 80 percent evaluation requires complete paralysis. When there is complete paralysis the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. §§ 4.123, 4.124, 4.124a, Codes 8520, 8620, 8720. The reports of the veteran's VA neurological and joint examinations in 1997 do not indicate the presence of any significant neurological deficits of the upper extremities, but VA EMG studies in November 1997 reveal that the ulnar nerve sensory distal latencies of both upper extremities were prolonged. The overall evidence does not reveal more than mild incomplete paralysis of the ulnar nerves of the right and upper lower extremities. Since the evidence does not show the presence of moderate incomplete paralysis or more severe deficits of the ulnar nerves of the right and upper lower extremities, ratings in excess of 10 percent for the peripheral neuropathy of the right and lower extremities are not warranted. Nor does the evidence show manifestations of these disorders warranting higher ratings for these conditions for a specific period or a "staged rating" at any time since the effective date of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The preponderance of the evidence is against the claims for higher ratings for peripheral neuropathy of the right and left upper extremities, status post total body radiation and stem cell transplant for NHL, initially assigned 10 percent evaluations, effective from June 1996, and the claims are denied. Since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The report of the September 1997 VA neurological examination of the veteran reveals decreased sensation to pinprick in a stocking distribution and slightly decreased proprioception and vibration in the lower extremities. At the October 1997 VA joint examination, he was again found to have diminished sensation in stocking distribution, and the November 1997 EMG studies revealed unobtainable sural sensory distal latency, bilaterally, and prolonged tibial motor distal latencies. The overall evidence indicates that the polyneuropathy of the lower extremities produce moderate incomplete paralysis of the sciatic nerves of each lower extremity, and that 20 percent evaluations for these conditions would better reflect the veteran's disability picture. 38 C.F.R. § 4.7. The evidence does not show neurological deficits of the lower extremities that produce more than moderate incomplete paralysis. After consideration of all the evidence, the Board finds that it supports granting higher ratings of 20 percent, for the peripheral neuropathy of the right and left lower extremities, effective from June 1996, and no more. Fenderson, 12 Vet. App. 119. III. Entitlement to a Higher Rating for a Disorder Manifested by Impaired Diffusion Capacity, Initially Assigned a 10 Percent Evaluation, Effective from June 1996 VA and private medical reports show that the veteran was treated and evaluated for various conditions in the 1990's. The more salient medical reports with regard to his claim for a higher rating for a disorder manifested by impaired diffusion capacity are discussed in the following paragraphs. During a VA medical examination for various conditions in August 1997, the veteran complained of medical problems following radiation and chemotherapy for NHL that was then in complete remission. He complained of progressive dyspnea on exertion and that he was unable to walk 100 yards without shortness of breath. He complained of a chronic dry cough that sometimes came in paroxysms so severe that he had emesis. He stated that he had a recurrent cold every 2 to 4 weeks with a sore throat and sneezing as well as intermittent bronchitis. He denied any sputum production or hemoptysis. He denied any fever, chills or night sweats. He complained of chest pain with his bronchitic infections. He denied headaches or TIA (transient ischemic attack) type symptoms. He denied paroxysmal nocturnal dyspnea, orthopnea, nocturia or edema. On examination, his lungs were clear to auscultation, bilaterally, with good air movement. He was noted to cough frequently when he took a deep breath. He was recommended for pulmonary function testing. In August 1997, he underwent pulmonary testing at a VA medical facility. The report of these tests note questionable effort by the veteran. An addendum dated in October 1997 to the report of the August 1997 VA examination notes that the pulmonary function studies demonstrated impaired diffusion capacity that was likely secondary to his radiation therapy. In December 1997, the veteran underwent repeated pulmonary function studies at a VA medical facility. The report of these studies show FEV-1 of 91 percent predicted, a ratio FEV-1/FVC of 91 percent predicted, and DLCO of 61 percent predicted. The veteran's claim for a higher rating for a disorder manifested by impaired ventilatory defect is well grounded, meaning it is plausible. The Board finds that all relevant evidence has been obtained with regard to the claim and that no further assistance to the appellant is required to comply with VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). A noncompensable evaluation is warranted for mild chronic bronchitis manifested by slight cough, no dyspnea, and few rales. A 10 percent evaluation requires moderate chronic bronchitis manifested by considerable night or morning coughing, slight dyspnea on exercise, and scattered bilateral rales. A 30 percent evaluation requires moderately severe chronic bronchitis manifested by persistent coughing at intervals throughout the day, considerable expectoration, considerable dyspnea on exercise, rales throughout the chest, and beginning chronic airway obstruction. A 60 percent evaluation is warranted for severe chronic bronchitis manifested by a severe, productive cough; dyspnea on slight exertion; and pulmonary function tests indicative of severe ventilatory impairment. A 100 percent rating is warranted where the symptoms are pronounced, with a copiously productive cough and dyspnea at rest, pulmonary function tests showing a severe degree of chronic airway obstruction, and symptoms of associated severe emphysema or cyanosis and findings of right-sided heart involvement. 38 C.F.R. § 4.97, Code 6600, effective prior to October 7, 1996. The regulations for the evaluation of diseases of the respiratory system were revised, effective October 7, 1996. 61 Fed. Reg. 46720-46731 (Sept. 5, 1996). When regulations are changed during the course of the veteran's appeal, the criteria that are to the advantage of the veteran should be applied. Karnas v. Derwinski, 1 Vet. App. 308 (1991). A 10 percent rating is warranted for bronchitis or COPD with FEV-1 of 71 to 80 percent predicted; or FEV-1/FVC of 71 to 80 percent predicted; or DLCO (SB) 66 to 80 percent predicted. A 30 percent rating requires FEV-1 of 56 to 70 percent; or FEV-1/FVC of 56 to 70 percent; or DLCO (SB) 56 to 80 percent predicted. A 60 percent rating is warranted for bronchitis or COPD with FEV-1 of 40 to 55 percent predicted; or FEV-1/FVC of 40 to 55 percent; or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 40 to 55 percent predicted; or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation requires FEV-1 less than 40 percent of predicted value; or FEV-1/FVC less than 40 percent; or DLCO (SB) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo (echocardiogram) or cardiac catheterization); or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Code 6600 or 6604, effective as of October 7, 1996. The medical evidence confirms the veteran has impaired diffusion capacity-as demonstrated by the pulmonary function studies. The VA report of the pulmonary function studies conducted in August 1997 indicate questionable effort by him and, consequently, will not be used to evaluate the severity of the disorder manifested by impaired diffusion capacity. However, the VA report of the pulmonary function studies subsequently conducted in December 1997 show a FEV-1 of 91 percent predicted, a ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC) of 91 percent predicted, and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 61 percent predicted. These findings support the assignment of a 30 percent rating for the veteran's respiratory disability under the criteria of diagnostic code 6600, effective as of October 7, 1996. The medical evidence does not show other symptoms of a respiratory disorder, such as persistent cough at intervals throughout the day, considerable expectoration, considerable dyspnea on exercise, rales throughout the chest or other manifestations that produce moderately severe ventilatory impairment in order to support the assignment of a 30 percent rating for the veteran's respiratory disability under the criteria of diagnostic code 6600, effective prior to October 7, 1996. The criteria of diagnostic code 6600, effective as of October 7, 1996, may not be used to support the assignment of a higher rating for the veteran's respiratory disorder prior to the date of the revised regulations in the absence of such authority in the regulations that is not found. Rhodan v. West, 12 Vet. App. 55 (1998). Hence, the preponderance of the evidence is against the claim for a higher rating for the veteran's respiratory disorder prior to October 7, 1996. Nor does the evidence show manifestations of the disorder warranting a higher rating for this condition for a specific period or a "staged rating" at any time since the effective date of the claim other than based on the change in the regulatory criteria noted above. Fenderson, 12 Vet. App. 119. After consideration of all the evidence, the Board finds the preponderance of the evidence is against the claim for a higher rating for a disorder manifested by impaired diffusion capacity prior to October 7, 1996, and this portion of the claim is denied. Since the preponderance of the evidence is against this portion of the claim, the benefit of the doubt doctrine is not for application with regard to it. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. The evidence, however, supports granting a 30 percent evaluation for this disorder, effective from October 7, 1996, and this portion of the claim is granted. ORDER The claim for service connection for a disorder manifested by sterility is denied as not well grounded. Higher ratings for peripheral neuropathy of the right and left upper extremities, status post total body radiation and stem cell transplant for NHL, initially assigned 10 percent evaluations, effective from June 1996, are denied. Higher ratings of 20 percent, effective from June 1996, for peripheral neuropathy of the right and left lower extremities, status post total body radiation and stem cell transplant for NHL, are granted, subject to the regulations applicable to the payment of monetary benefits. A higher rating prior to October 7, 1996, for a disorder manifested by impaired diffusion capacity is denied, and this portion of the appeal is denied to this extent; a higher rating of 30 percent, effective as of October 7, 1996, for a disorder manifested by impaired diffusion capacity is granted, and this portion of the appeal is granted to this extent. REMAND With regard to the claim for service connection for an eye condition, the veteran underwent a VA eye examination in August 1997. The report of this examination shows no eye disorders. Since then, a report dated in September 1999 from Preston Lowe, doctor of optometry, notes that the veteran has cataracts of both eyes, and a report dated in September 1999 from Teresa C. Gentile, M.D., indicates a direct correlation between cataracts and radiation therapy for NHL. Under the circumstances, the duty to assist the veteran requires providing him with a special VA examination to ascertain the nature and extent of any eye disorder and to obtain an opinion as to the etiology of any eye disability found. Moore v. Derwinski, 1 Vet. App. 401 (1991). The veteran requests service connection for a dental condition for the purpose of obtaining outpatient VA dental treatment. In October 1997, he underwent a VA dental examination and the dentist who conducted this examination opined that the veteran's dental problems were not related to radiation therapy for NHL. Since then, private dental reports of his treatment from 1988 to 1989 have been associated with the claims folder as well as contrary opinions from other dentists. A report dated in September 1998 from Stephen T. Sonis, D.M.D., indicates that it was quite possible that the veteran's chemotherapy and radiation treatment for NHL could have caused changes in salivary function and composition that increased his risk for dental caries and subsequent breakdown of his teeth that required extraction. Another report dated in December 1998 from Troy E. Daniels, DDS, opines that it is certainly possible that the veteran sustained long-term or permanent qualitative and quantitative changes in his saliva from his NHL treatment that caused the increase in the dental caries observed by Dr. McLaughlin (reports with similar opinions from this dentist are of record). Under the circumstances, the duty to assist the veteran requires providing him with a special VA dental examination to ascertain the nature and extent of any dental disorder and to obtain an opinion as to the etiology of any dental condition found. Moore, 1 Vet. App. 401. With regard to the claim for an increased evaluation for residuals of NHL manifested by low back pain and bilateral knee pain, the report of his VA neurological examination in September 1997 indicates that it was difficult to assess the motor strength in the lower extremities due to giveaway weakness secondary to back pain. The report of the veteran's VA joint examination indicates the presence of low back pain and bilateral knee pain related to his NHL, but does not provide an opinion as to the current severity, including functional impairment, of the veteran's low back and bilateral knee conditions. The report of the veteran's VA joint examination also indicates that the veteran may have a mid back disability (degenerative changes of the dorsal spine found on X-ray) as well as a lumbosacral area disability. If he does, the impairment produced by each disability should be separately noted, as well as the ranges of motion of the low back that the examiner considers normal. Therefore, the Board believes the veteran should undergo another VA joint examination to determine the severity of his low back and bilateral knee conditions-including the extent he may have additional functional impairment due to his pain and painful motion, limited or excess movement, weakness, premature fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202 (1995). In view of the above, the case is REMANDED to the RO for the following actions: 1. The veteran should be scheduled for a VA eye examination to determine the nature and extent of any eye disability, and to obtain an opinion as to the etiology of any eye condition found. The examiner should give a fully reasoned opinion on the etiology of any eye condition found, including whether it is at least as likely as not that any eye condition is due to chemotherapy and radiation treatment for the veteran's NHL. The examiner should support his or her opinion by discussing medical principles as applied to specific medical evidence in the veteran's case, including the above-noted reports concerning the veteran's eye problems. In order to assist the examiner in providing the requested information, the claims folder must be made available to the physician and reviewed prior to the examination. 2. The veteran should be scheduled for a dental examination to determine the nature and extent of any dental problems, and to obtain an opinion as to the etiology of any dental problems found. The examiner should give a fully reasoned opinion on the etiology of any dental condition found, including whether it is at least as likely as not that any dental problem is due to chemotherapy and radiation treatment for the veteran's NHL. The dentist should support his or her opinion by discussing medical principles as applied to specific medical evidence in the veteran's case, including the above-noted dental reports. In order to assist the examiner in providing the requested information, the claims folder must be made available to the dentist and reviewed prior to the examination. 3. The veteran should be scheduled for a VA orthopedic examination to determine the severity of his low back and bilateral knee conditions. All indicated studies, including X-rays of the dorsal and lumbosacral spine, should be performed and all clinical findings reported in detail, including ranges of motion with the ranges of motion considered normal by the examiner reported in parentheses. The examiner should be asked to determine whether the veteran has painful motion and whether his joints show signs of weakness, premature/excess fatigability or incoordination; to the extent possible, these determinations should be expressed in terms of additional functional impairment attributable to these symptoms-due to, for example, an additional decrease in his range of motion such as when his symptoms flare up. If the disabilities of the mid back and low back are found, the examiner should specifically note the impairment attributable to each condition, if any. The examiner should support the opinions by discussing medical principles as applied to specific medical evidence in this case. In order to assist the examiner in providing the requested information, the claims folder should be made available to the physician and reviewed prior to examination. 4. The RO should review the reports of the examinations to ensure they are in compliance with the directives of this REMAND. If not, immediate corrective action should be undertaken. 38 C.F.R. § 4.2. 5. Upon completion of the above development, and any additional development deemed warranted by the record, the RO should readjudicate the claims for service connection for an eye condition, for service connection for a dental condition for the purpose of obtaining VA outpatient dental treatment, and for a higher rating for the low back and bilateral knee pain, initially assigned a 10 percent evaluation, effective from June 1996. If the benefits requested by the veteran are not granted to his satisfaction, then he and his representative should be provided an appropriate supplemental statement of the case and given an opportunity to respond before the appeal is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument concerning the claims the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. Keith W. Allen Acting Member, Board of Veterans' Appeals