BVA9502312 DOCKET NO. 92-13 084 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES Entitlement to service connection for bilateral defective vision, residuals of head trauma, and residuals of back, neck, and right middle finger injuries. ATTORNEY FOR THE BOARD D. B. Weiss, Associate Counsel INTRODUCTION The veteran had active military service from August 3, 1977, to September 19, 1977, and from November 14, 1989, to February 1990. CONTENTIONS OF APPELLANT ON APPEAL The veteran alleges that service connection should be granted for the disorders at issue. He points out that his vision was acceptable at his second service entrance but not at his final discharge. He specifically alleges that he was abused by being pushed and banged on the head by a sergeant, with momentary loss of consciousness, as a trainee at Fort Knox, and that this ruined his vision and precipitated his discharge from service. He asserts that he now sees colors of light, in motion, about the size and shape of a half dollar, which block the central part of his visual field bilaterally. In essence, therefore, his claim pertinent to his eyes is for service connection, either directly or by aggravation, for decreased visual acuity bilaterally. He also claims that he sustained a bruised middle finger in the incident with the sergeant and a snapped neck in November 1989. In accordance with the provisions of Thurber v. Brown, 5 Vet.App. 119 (1993), the veteran was provided with a copy of the medical literature cited in this decision, in a letter dated in November 1994. The veteran did not respond to this letter. DECISION OF THE BOARD The Board of Veterans' Appeals (Board), in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims. FINDINGS OF FACT 1. Right eye defective vision, a choroid abnormality, amblyopia, anisomotropia and myopia, preexisted the first period of service and did not undergo increase in pathological severity in service. 2. Left eye defective vision was not shown in the first period of service. 3. Bilateral defective vision preexisted the second period of service and any increase in severity is not shown to be other than natural progress of the preexisting condition. 4. Bilateral maculopathy, first shown in the second period of service, has not been shown at any time after such service. 5. Refractive error of the eye is not a disease or injury for which service connection can be granted. 6. Residuals of head trauma are not shown; a small bony excrescence on the right parietal area and subjective headaches are not shown to be related to service. 7. Residuals of back, neck, and right middle finger injuries are not shown; a thickening of the base of the third right finger at the knuckle, subscapular tenderness, and subjective sensations of pain and creaking in the neck are not shown to be related to service. CONCLUSIONS OF LAW 1. Bilateral defective vision was not incurred in or aggravated by active peacetime service. 38 U.S.C.A. §§ 1131, 1153, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.306 (1993). 2. Residuals of head trauma, and residuals of back, neck, and right middle finger injuries were not incurred in or aggravated by active peacetime service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, we note that the provisions of 38 U.S.C.A. § 5107 have been met, in that the claims are well grounded and adequately developed insofar as possible. The veteran requested and has been medically recommended for neuro-ophthalmologic examination. He further expressed a commitment to cooperate with the examiner. To address these issues, in April 1994, the Board remanded this case to allow additional evidentiary development, to include examination. The regional office's (RO) attempts to accomplish the development were fruitless because the RO was unable to contact the veteran. The RO is required to attempt to contact the veteran at his latest address of record. 38 C.F.R. § 3.1(q) (1993). Here, the RO attempted to reach the veteran by letter at both his most recent address of record, and at his old address of record. These letters were returned as undeliverable by the Post Office. Mindful that the "...duty to assist is not always a one- way street," we proceed, constrained to make our decision based on the current evidence of record. See Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active peacetime service. 38 U.S.C.A. § 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs (VA) to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a). The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A preexisting disease or injury will be considered to have been aggravated by active service, where there is an increase in disability during service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity in service. This includes medical facts and principles which may be considered to determine whether the increase was due to the natural progress of the condition. Aggravation of a preexisting disease or injury may not be conceded where the condition underwent no increase in severity during service on the basis of all of the evidence of record pertinent to the manifestations of the disability prior to, during, and subsequent to service. Consideration will be given to the circumstances, conditions, and hardships of service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). There are medical principles which are so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of a disability prior to service is established, no additional or confirmatory evidence is necessary. Similarly, manifestations of lesions or symptoms of chronic disease from date of enlistment or so close thereto that the disease could not have originated in so short a period will establish preservice existence thereof. Congenital or developmental defects and refractive error of the eye are not diseases or injuries within the meaning of the applicable legislation. 38 C.F.R. § 3.303(c). At the enlistment medical examination in July 1977, the veteran made no pertinent complaints. Examination was within normal limits in all relevant respects except for a notation of choroidal "figment" in the right eye and congenital amblyopia of the right eye, due to high anisometropia. A Report of Medical History included a notation of "myopia." Left eye visual acuity was 20/20, uncorrected. Right eye vision was 20/400, reportedly corrected to "20/400". On August 8, 1977, approximately 5 days after entry into service, optometry examination revealed possible old juxtapapillary choroiditis, although it was found that no treatment was needed. Uncorrected, the left eye's vision was 20/20, and the right eye's vision was 20/400. The veteran was separated from service on September 19, 1977, after 1 month and 17 days of service. A report of a separation physical examination is not of record. At an Army National Guard enlistment physical examination in May 1989, the right eye had vision of 20/400, corrected to 20/100. The left eye had distant vision of 20/25, which was not corrected, and near vision of 20/30, corrected to 20/25. The summary of defects included slight exotropia "less than 40," without diplopia, and right eye amblyopia exanopsia. Myopia was also noted on a Report of Medical History. The veteran entered his second period of service on November 14, 1989. An ophthalmology consultation was requested on November 17, 1989, because of decreased visual acuity in both eyes, peripapillary atrophy in the right eye, and a macular lesion in the left eye which was questionably solar maculopathy. The consultation report, dated November 22, 1989, shows uncorrected visual acuity of 20/400 in the right eye and 20/25+2 in the left eye. Amblyopia since childhood was noted. The examination resulted in an assessment of amblyopia of the right eye, secondary to anisometropia, and maculopathy with a lamellar hole in the left eye, thought to be consistent with "solar," but, it was noted, the veteran gave no history. A fluorescein angiogram was planned. A fluorescein angiogram was done in mid-January 1990. It was noted that the veteran's visual acuity had worsened. The reports contain uncorrected visual acuity readings of 20/400 in the right eye and 20/30+1 and 20/30+2 in the left eye. Results of the angiogram led to a diagnostic assessment of maculopathy of uncertain etiology consistent with photic injury. A Medical Board report shows that, in the optometry clinic, the veteran was seen to have decreased vision and peripapillary atrophy with maculopathy. He complained of "light" in his central vision. The Medical Board noted that right eye visual acuity was 20/400, corrected to 20/400+, and that left eye acuity was 20/30, corrected to 20/25+. Muscle balance testing revealed a small right exotropic flick. The pupils were normal. Fundoscopic examination showed some peripapillary atrophy, particularly temporally of the right eye. A whitish reflex off the right macula without detectable fovea was seen, with some very fine yellowish spots noted at the level of the retinal pigment epithelium in the right eye. On the left eye, there was a lamellar hole with a very small foveolar reflex centrally. The periphery was within normal limits, as were the vessels. A fluorescein angiogram failed to reveal any significant abnormalities within the (left) macula except a very small hyperflourescence in the left macula in the mid to late portion of the study. The angiogram was not well focused in the right eye. The diagnoses were anisometropia, amblyopia, and maculopathy. The report contains an opinion that the maculopathy was likely to deteriorate resulting in further decrease in vision at some point in the future. A physical profile report dated in January 1990 lists amblyopia, in the right eye, and maculopathy, both eyes, as medical conditions. On February 1, 1990, the veteran complained of pain in the "knuckle" of his right hand, having no feeling in either arm, and of neck pains. He was sent to the radiology clinic and then to duty. The next day, he gave a history of uncontrollable shaking of his arms and hands, and a sharp pain in the center of his back radiating into his occipital and parietal lobes, having occurred that morning. He stated that he had been in a scuffle with another service member and had knocked his head on a wall and fallen on the floor. The examiner noted that the veteran was in no acute distress. Ecotrin was prescribed. The veteran was separated from service on February 26, 1990. VA eye examination in March 1990, approximately one month after separation from service, revealed the veteran's complaints of defective vision and of seeing a clockwise spinning wheel of light in "colors" in his central vision. These were described as blue, yellow, and red, and spinning very fast all day long. Reportedly, the only change was in the morning upon awakening, when the spin was slow, but the spinning soon became fast. The wheel was about 3 inches in diameter at 2 feet distant, and about 6 inches at 18 feet. The veteran alleged that this started in November 1989 after a smallpox vaccination, when he noted his vision to be hazy. One week thereafter, he said, he hit his head on the right rear temporal lobe on a wall, after which he became very dizzy and unstable. Later he began to see the lights. On examination, the fundi, blood vessels, iris, and pupils were within normal limits, the nerve head had good color, and the dilated media were clear bilaterally. Uncorrected visual acuity was hand motion at 4 feet in the right eye and 8/200 in the left eye, not correctable by refraction. Dilated fundi examination showed a cup/disc ratio of 0.2. The macula area was clear with good foveal reflex. No efferent pupillary defect was present. Slit lamp angles were deep and open. The veteran's eyes could not follow a target but were capable of full mobility. The examiner noted that by visual field and visual acuity testing, the veteran was blind, but the assessment was that he did not act blind. There was high myopia on the right and low myopia on the left, but, it was noted, this had no impact on visual acuity. The eyes were found to be very normal, including intraocular pressures, cup/disc ratio, and fundi. A neurologic examination was recommended. At VA general medical examination in March 1990, the veteran complained of head trauma in service. He reported ongoing headaches. On examination, the examiner noted a small bony excrescence on the right parietal area, which was described as periodically symptomatic. This was described as a small protuberance of bone the size of a walnut at most, near the temporal area where the veteran had allegedly been struck. In the examiner's opinion, this was possibly an artifact. The veteran also complained of subjective symptoms of cervical spine pain and tingling secondary to this scuffle with the sergeant, which was not reflected by abnormality on examination. The relevant diagnosis was history of back injury, referring to neck injury. The veteran reported injury to the knuckles of the right hand as a result of this hand having been stepped upon by the staff sergeant, with continuing symptoms of pain when lifting with his right middle finger. However, no clear abnormalities of the right hand or its knuckles could be identified on examination. The pertinent diagnosis was history of injury to the right hand with bruised knuckles, now healed. The examiner additionally noted that the veteran had previously obtained a job as a security guard but could not read properly apparently due to his visual problems and therefore could not hold the job. VA neurological examination in June 1990 revealed that the veteran's reflexes were equal and his plantar responses were flexor. The examiner reported that the veteran did not cooperate with the examination. The impression was normal neurological examination. VA psychological examination in March 1991 showed that the veteran complained of visual phenomena including a circle of light interfering with his ability to see and read, and preventing him from obtaining a driver's license. He reported that he found and recycled scrap metal for a living. The psychologist noted inconsistencies in the veteran's history in that he claimed to read widely about brain function but also said that he could not watch television or read a newspaper apparently due to his visual problems. His visual problems also did not interfere with his ability to find and recycle metal cans. Testing was limited by the veteran's claims of defective vision. Visual spatial testing revealed that the veteran could visualize large print and simple drawings only by looking slightly above the stimuli. He could discern the gist of the drawings but could not see the details. It was not clear whether these defects were sensory or at the central nervous system level. In the examiner's opinion, the test results, combined with the history, were suggestive of partial complex seizures or a functional disorder with exaggeration of symptoms for secondary gain. At special VA orthopedic examination in March 1991, the veteran 's cervical spine was normal in range of motion, although he reported a creaking sensation when he moved "lateral ward" on the left and right side of the neck. He also reported a pulling sensation on the left side of the neck with radiation to the right scapula. The upper extremities were normal except for a mild swelling on the right knuckle area at the base of the 3rd finger, without limitation of motion, deformity, or other swelling. The lumbar spine had normal curvature and no limitation of motion. The pertinent diagnoses were: (1) history and residuals of neck injury without limitation of motion but with creaking sensation and pain radiating down to the scapular area on maneuvers, (2) history and residuals of injury to the right hand with subjective symptoms of pain and swelling in the knuckle, and (3) history and residuals of upper back injury with tenderness on palpation of the right subscapular area of the muscles without swelling or deformities. Cervical spine and right hand X-rays were within normal limits. We have reviewed all of the relevant evidence. With regard to the veteran's claim for service connection for decreased vision in the eyes and the presumption of soundness, defective vision was noted at entry into each period of service. In any event, history and findings during each period of service clearly and unmistakably show that the defective vision existed prior to each period of service. The veteran himself argues in his substantive appeal that his bilateral defective vision was aggravated by service. 38 C.F.R. § 3.304(b). We also note that anisometropia, noted in both periods of service, is merely a difference in the refractive power of the two eyes; therefore, it will not be discussed further herein as, in itself, it is neither an ocular pathology nor a disease or injury. See 38 U.S.C.A. § 1131; Dorland's Illustrated Medical Dictionary 82 (26th ed. 1981). Regarding the evidence pertinent to the first period of service, it essentially shows that right eye defective vision of 20/400, noted at the entrance examination, preexisted that service. The left eye had normal visual acuity at the first service entrance, which is not shown to have become defective during that enlistment of one month and 17 days. Myopia, right eye choroidal "figment," congenital right eye amblyopia, and right eye defective vision were also noted at the first entrance examination. Possible old juxtapapillary chorditis was suspected during that service. No separation medical examination is available for the first period of service. Myopia is an error of refraction and is therefore not service- connectable. See 38 C.F.R. § 3.303(c); Dorland's Illustrated Medical Dictionary 863 (26th ed. 1981). Nothing is shown during this short period of service that was not shown at entry. Thus, the evidence discloses no basis for service connection for defective vision based on incurrence or aggravation in the first period of service. Regarding the second period of service, the evidence clearly and unmistakably shows that bilateral defective vision preexisted that service. Right eye vision was reportedly correctable to 20/100 and left eye vision was 20/25, at examination in May 1989, approximately 6 months prior to entry. Myopia, right eye amblyopia, and exotropia also were noted at that examination. Approximately 3 days into the second period of service, bilateral defective visual acuity was noted, along with amblyopia of the right eye and maculopathy of the left eye. Right eye visual acuity was not shown to be any different during the second period of service than during the first period of service. Left eye visual acuity appears to have declined during the second period of service and the decline appears to have been due to maculopathy. There is a question as to whether the maculopathy existed prior to service, since it was found approximately 3 days into service. Complicating the factual situation in this case is that, at separation from the second period of service, visual acuity was 20/400 in the right eye and about 20/30 in the left eye. On VA examination approximately one month later, visual acuity was reported as hand motion in the right eye and 8/200 in the left eye. Maculopathy was not found. The examiner clearly found that the findings were not reliable and recommended a neurological examination. The veteran did not cooperate with the neurological examination. The Board, however, remanded the case for a special examination to obtain medical evidence concerning the questions of what pathology preexisted the second period of service and whether any increase in pathology was due to any incident of service. The veteran could not be located for the examination. The state of the record is such that it will not support a finding that any additional pathology of the eyes was acquired during the second period of service or that any increase in the severity of preexisting pathology represented anything other than the natural progress of the condition. Therefore, the claim must be denied. As previously discussed, myopia is a refractive error and not service connectable. 38 C.F.R. § 3.303(c). The evidence relevant to the veteran's claims for service connection for residuals of head trauma shows that service records reveal a history of pain in the back radiating to the occipital and parietal lobes, following his head being knocked on a wall. Neither the present subjective complaints of headaches nor the finding of small bony excrescence on the right parietal area have been medically related to the service years. The VA general medical examiner thought, in fact, that the protuberance of bone was possibly an artifact. As a layman, the veteran is not medically qualified to render an opinion as to the etiology of his symptoms or the findings. See Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). Therefore, no residuals of a head trauma in service are shown, and service connection may not be granted for this reason. 38 C.F.R. § 3.303(a). Back, neck, and right middle finger injuries, similarly, are not service-connected. While the veteran reported in service that he had pain in the knuckle in his right hand, his neck, and his back, current examination fails to demonstrate any pathology which is medically indicated to have had its onset in or to have been aggravated during the periods of service. A mild swelling of the right knuckle area at the base of the third finger was seen on orthopedic examination; however, no abnormality is shown on X-ray. The neck currently demonstrates subjective sensations of creaking and pain, without objective corroboration by X-ray or on the physical examination. The veteran's back presently shows only tenderness on palpation of the subscapular area. In the case of these three alleged injuries, the veteran relates his symptoms and the findings on examination to incidents of trauma in service. However, the special VA orthopedic examiner drew no such causal relationships. As the veteran is a layman, he is not qualified to render a medical opinion on the etiology of his swollen right knuckle area at the base of the third finger, his subscapular tenderness, or his subjective sensations of neck pain and creaking. See Espiritu, 2 Vet.App. at 494. Therefore, service connection must be denied. ORDER Service connection for bilateral defective vision, residuals of head trauma, and residuals of back, neck, and right middle finger injuries is denied. WILLIAM J. REDDY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 State. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.