Citation Nr: 0005170 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 98-12 044 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an initial rating in excess of 30 percent for left eye aphakia secondary to penetrating intraocular foreign body with traumatic cataract, lysis of synechia and corneal adhesion. 3. Entitlement to an initial compensable evaluation for chronic bilateral ingrown nail of the great toes and second left toenail with onychomycosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Crawford, Counsel INTRODUCTION The veteran had active service from May 1974 to May 1994. This appeal arises from a June 1997 rating decision in which the RO denied entitlement to service connection for bilateral hearing loss and granted service connection for left eye aphakia, rated at 30 percent, and chronic bilateral ingrown nails of the great toes and second left toenail with onychomycosis, rated as noncompensably disabling. FINDINGS OF FACT 1. The medical evidence fails to show that the veteran currently has bilateral hearing loss, which is recognized as a disability by VA regulation. 2. Regarding the increased rating claims, all evidence necessary for an equitable disposition of the veteran's claims has been obtained. The duty to assist has been fulfilled. 3. The veteran's left eye aphakia is manifested by uncorrected near visual acuity to 20/400 without evidence of diplopia or visual field deficit. The veteran's current rating is the maximum schedular rating for blindness in one eye, without anatomical loss or a serious cosmetic defect, when service connection is not in effect for the other eye. 4. The veteran's chronic bilateral ingrown nails of the great toes and second left toenail with onychomycosis is manifested by deformity of each nail due to onychomycosis with inflammation erythema of the left great toe due to chronic irritation. The disability is productive of moderate impairment and no more. 5. The veteran's disabilities are not characterized by unusual or exceptional disability. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for bilateral hearing loss is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria required for an initial rating in excess of 30 percent for left eye aphakia are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.3, 4.7, 4.84a, Diagnostic Code 6029 (1999). 3. The criteria required for an initial rating to 10 percent for chronic bilateral ingrown nail of the great toes and second left toenail and onychomycosis are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.20, Part 4, Diagnostic Codes 5284, 7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection The veteran seeks service connection for bilateral hearing loss. Service connection may be established for a disability resulting from personal injury incurred or disease contracted in the line of duty or for aggravation of a preexisting injury or disease. 38 U.S.C.A. §§ 1110, 1131 (West 1991). The regulations also state that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Continuity of symptomatology is required where the condition noted in service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for a chronic disease, including sensorineural hearing loss, if manifest to a degree of 10 percent or more within one year from the date of separation from such service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Nonetheless, for the purposes of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). Well-grounded claims A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a); Anderson v. Brown, 9 Vet. App. 542, 545 (1996). As such, the threshold question with regard to the veteran's claims for service connection is whether the claims are well grounded pursuant to 38 U.S.C.A. § 5107. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The test is an objective one which explores the likelihood of prevailing on the claim under the applicable law and regulations. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Thus, although a claim need not be conclusive to be well grounded, it must be accompanied by supporting evidence. 38 U.S.C.A. § 5107(a); Tirpak, supra. 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 evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence.) Caluza v. Brown, 7 Vet. App. 498 (1995). In the alternative, there must be evidence that shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. See Savage v. Gober, 10 Vet. App. 488 (1997). For the purposes of determining well groundedness, the credibility of the evidence is presumed. See Robinette v. Brown, 8 Vet. App. 69, 75 (1995); Justus v. Principi, 3 Vet. App. 510 (1992). Where the determinative issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a). Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 494, 494 (1992). Analysis In this case review of the evidence shows that the veteran's claim is not well grounded. The medical evidence fails to show that a current diagnosis of bilateral hearing loss has been made. The Board acknowledges that service medical records show on periodic examination in May 1984, hearing loss since 1983 due to occupation in hazardous noise area was noted, and at that time, audiometric findings showed that the veteran's puretone threshold levels ranged from 15 to 30 decibels on the right and 5 to 25 decibels of the left for the frequencies between 500 and 4000 Hertz, respectively. On periodic examination in February 1990, puretone threshold levels on the right ranged from 10 to 35 decibels and from 10 to 25 decibels on the left. It is also acknowledged that on examination in March 1993 the veteran indicated that he had hearing loss because he had difficulty with hearing over the phone. Audiometry findings also showed puretone levels to 10, 15, 30, 35, and 35 decibels on the left and 10, 5, 10, 10, 10, and 15 decibels on the right, for the frequencies ranging from 500 to 3000 Hertz, respectively. Additionally, in a March 1993 statement, the Hearing Conservation Program identified a change in the veteran's hearing when compared to his last baseline test. However, in spite of the veteran's assertions of experiencing progressive bilateral hearing loss since 1991 and being exposed to excessive noise from aircraft, air tools, and shop equipment while in service, audiometry findings on VA examination in May 1997 fail to show that he currently has bilateral hearing loss, which is recognized as disability by VA regulation. Audiometric test results show pure tone threshold levels to 10, 10, 20, 25, and 25 decibels on the right and 15, 15, 10, 20, and 20 decibels on the left for the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz, respectively. The puretone average on the right was 20 and 16 on the left. Speech recognition was 100, bilaterally. The examiner noted that the best estimate of the veteran's organic hearing sensitivity was hearing within normal limits by VA standards, bilaterally. As shown above, in spite of the veteran's contentions of having bilateral hearing loss, the recent medical evidence fails to show that a diagnosis of hearing loss has been made. For VA purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Here, the veteran's hearing is within normal limits by VA standards. Accordingly, his claim is not well grounded. Gilpin v. West, 155 F.3d 1353 (1998); Rabideau, supra; see Brammer v. Derwinski, 3 Vet. App. 223 (1992). Additionally, although the Board acknowledges the veteran's in-service findings, which are indicative of hearing loss, see Hensley, supra, and his current complaints of hearing loss, it is noted that where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" is required. Grottveit at 93. In this case, such evidence is not present. Here, the veteran's statements and contentions represent the only evidence of record suggesting that he has bilateral hearing loss, as recognized by VA standards. Because the veteran is not competent to render such diagnoses and etiologically relate those diagnoses to service, his claim is not well grounded. Espiritu, supra. In this case the duty to inform as mandated in Robinette v. Brown, 8 Vet. App. 69 (1995) and 38 U.S.C.A. § 5103(a) (West 1991) has been discharged. In the June 1998 statement of the case, the veteran was adequately apprised of what evidence was required to establish a well-grounded claim and of what evidence was necessary to complete his case. Robinette, supra. Such evidence however has not submitted. In addition, there does not appear to be any pertinent outstanding evidence of which VA is on notice; thus, there is no duty to assist. 38 U.S.C.A. § 5107(a); Morton v. West, 12 Vet. App. 477 (1999); Epps v. Gober, 126 F.3d. 1464 (Fed. Cir. 1997); Grottveit, supra; 38 C.F.R. § 3.159. The veteran's claim is denied. Increased Ratings As noted above, in June 1997, the RO granted service connection for left eye aphakia, rated at 30 percent, and chronic bilateral ingrown nails of the great toes and second left toenail and onychomycosis, evaluated at 0 percent. The veteran appealed therefrom. Accordingly, the veteran was awarded service connection for a disability and he appealed that original rating. When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995); see also AB v. Brown, 6 Vet. App. 35 (1993). The VA, therefore, has a duty to assist. 38 U.S.C.A. § 5107(a). Upon reviewing the record, the Board is satisfied that all necessary evidence has been received for an equitable disposition of the veteran's appeal and adequately developed. Id. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. Different diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3. Left eye aphakia The veteran asserts that he is entitled to an increased rating for left eye aphakia because he is unable to wear soft contact lens and the disability affects his depth perception. The Rating Schedule provides that loss of use or blindness of one eye, having only light perception, will be held to exist when there is inability to recognize test letters at 1 foot (.30m.) and when further examination of the eyes reveals that perception of objects, hand movements or counting fingers cannot be accomplished at 3 feet (.91m.), lesser extents of visions, particularly perception of objects, hand movements, or counting fingers at distances less than 3 feet (.91 m.), being considered of negligible utility. 38 C.F.R. § 4.79 (1999). Traumatic cataract which is preoperative is rated on impairment of vision, and on impairment of vision and aphakia when the disorder is postoperative. 38 C.F.R. § 4.84a, Diagnostic Code 6027 (1999). For bilateral or unilateral aphakia a minimum 30 percent rating is applied not to be combined with any other rating for impaired vision, and when only one eye is aphakic, the eye having poorer corrected visual acuity, if also service-connected, will be rated on the basis of its acuity without correction. When both eyes are aphakic, both will be rated on corrected vision. The corrected vision of one or both aphakic eyes will be taken one step worse than the ascertained value, however, not better than 20/70 (6/21). The combined ratings for disabilities of the same eye should not exceed the amount for total loss of vision of that eye unless there is an enucleation or a serious cosmetic defect added to the total loss of vision. 38 C.F.R. § 4.84a, Diagnostic Code 6029. Unhealed eye injuries in chronic form are rated from 10 percent to 100 percent based on impairment of visual acuity or field loss, pain, rest requirements or episodic incapacity combining an additional 10 percent rating during continuous active pathology. 38 C.F.R. § 4.84a, Diagnostic Code 6009 (1999). Blindness in one eye, having only light perception, is 30 percent disabling, if visual acuity in the other eye is 20/40 (6/12). Blindness in one eye, having only light perception, is 40 percent disabling, if visual acuity in the other eye is 20/50 (6/15) or if there is an anatomical loss of the eye and visual acuity in the other eye is 20/40. Blindness in one eye, having only light perception, is 50 percent disabling, if visual acuity in the other eye is 20/70 (6/21). See 38 C.F.R. § 4.84a, Diagnostic Codes 6066, 6069, 6070 (1999). Combined ratings for disabilities of the same eye should not exceed the rating for total loss of vision of that eye, unless there is enucleation or a serious cosmetic defect added to the total loss of vision. 38 C.F.R. § 4.80 (1999). The best distant vision obtainable after best correction by glasses will be the basis of rating visual acuity, except in cases of keratoconus in which contact lenses are medically required. 38 C.F.R. § 4.75 (1999). Compensation is payable for certain combinations of service- connected and nonservice-connected disabilities, including blindness in one eye as a result of service-connected disability and blindness in the other eye as a result of nonservice-connected disability, as if both disabilities were service-connected, provided the nonservice-connected disability is not the result of the veteran's own willful misconduct. 38 C.F.R. § 3.383(a)(1) (1999). In determining the effect of aggravation of visual disability, even though the visual impairment of only one eye is service connected, evaluate the vision of both eyes, before and after suffering the aggravation, and subtract the former evaluation from the latter except when the bilateral vision amounts to total disability. In the event of subsequent increase in the disability of either eye, due to intercurrent disease or injury not associated with the service, the condition of the eyes before suffering the subsequent increase will be taken as the basis of compensation subject to the provisions of 38 C.F.R. § 3.383(a). 38 C.F.R. § 4.78 (1999). In this case the service medical records show that on entrance examination in April 1974 visual acuity of the right and left eye was 20/20. In July 1976, the veteran sustained a penetrating foreign body of the left eye with a corneal laceration. The veteran thereafter noticed a sudden decrease in visual acuity and mild foreign body sensation. On hospital admission, the veteran's visual acuity was 20/40 with a pinhole in the left eye and 20/20 of the right eye. The right eye was entirely within normal limits. For the left eye, findings showed moderate ejection, although the pupils were reactive and extraocular motility was within normal limits with orthophoria. Slight lamp examination revealed a formed anterior chamber, a jagged Z-shaped laceration of the cornea, and underlying perforated injury to the iris. Additionally, there was a rent in the anterior capsule of the lens, opacification localized in the lens behind the area of the tear, and apparent laceration of the posterior capsule. Funduscopic examination showed a grossly normal posterior polar detail. However, a large intraocular foreign body which was sunk inferiorly intraocularly and sitting in the vitreous cavity was also observed. While hospitalized, the veteran underwent a repair of the corneal laceration; aspiration of traumatic cataract; and removal of intraocular foreign body. The diagnoses were laceration of the corneal left eye repaired with penetrating intraocular foreign body (No major artery or nerve involvement) and traumatic cataract of the left eye. Thereafter, the veteran developed a pupillary membrane with peaked pupil. Consequently, he was rehospitalized in August 1977. On hospital admission in August 1977 examination revealed serous fluid behind the left membrane. Vision of the right eye was 20/20 and of the left, finger count at 3 feet with a +10.00 lens. The veteran could see 20/60. Findings also show that the veteran was orthotropic; applanation tonometry of the right eye was 13 whereas it was 12 of the left eye; and the pupil of the right eye was normal but on the left it was irregular and pulled nasally. Slight lamp examination of the right eye revealed an old central scar probably from a previous corneal foreign body and of the left eye there was a central corneal scar from the laceration, pupillary membrane with adhesions to the cornea at 9:00 o'clock. Fundus of the right eye was normal whereas it could not be seen of the left eye. While hospitalized, the veteran underwent a discission of the pupillary membrane of the left eye with lysis of synechia and the corneal adhesion. The diagnosis was traumatic corneal scar and pupillary membrane of the left eye; discission of pupillary membrane and lysis of posterior synechia and corneal adhesion of the left eye. Service medical records also contain a June 1980 consultation report noting that the corneal scar of the right was old and did not impair the veteran's vision and that in spite of the aphakic of the left eye, the veteran had surprisingly good vision considering the corneal scar and pupillary membrane. A May 1984 periodic examination report shows defective distant visual acuity of the left correctable to 20/30 and defective near visual acuity of the left uncorrectable. Distant visual acuity of the right was 20/17 and near visual acuity was 20/20. A February 1990 periodic examination report and March 1990 Optometry Record show that near and distant visual acuity of the right was 20/20. For the left eye, the February 1990 examination report shows distant and near vision corrected to 20/20. The Optometry Record shows visual acuity to 20/400. Defective visual acuity adequately corrects was noted on the February 1990 examination report. On visual examination in April 1997, uncorrected visual acuity of the right both near and far was 20/20. Uncorrected vision, both near and far, of the left eye was 20/400. Corrected near vision of the left eye was 20/30 and corrected far vision was 20/25. No evidence of diplopia or visual field deficit was present. The impression was aphakia of the left, corneal scars of the left greater than right, and posterior capsule opacity of the left. In June 1997, the RO granted service connection for left eye aphakic secondary to penetrating intraocular foreign body with traumatic cataract, lysis of synechia, and corneal adhesion and assigned a 30 percent evaluation, effective from March 12, 1997. After reviewing the evidence, the Board finds that entitlement to an increased rating in excess of 30 percent is not warranted. The veteran's left eye aphakia has been evaluated under 38 C.F.R. § 4.84, Diagnostic Code 6029. Under that provision, unilateral or bilateral aphakia warrants a 30 percent evaluation. Although a 30 percent rating is the minimum evaluation that can be received, that rating provision also provides that it is not to be combined with any other rating for impaired vision and that the combined rating for the same eye should not exceed the evaluation for the total loss of vision of that eye, unless there is an enucleation or a serious cosmetic defect added to the total loss of vision. 38 C.F.R. §§ 4.80, 4.84a, Diagnostic Code 6029. In this case the clinical data is completely devoid of evidence illustrative of enucleation, a serious cosmetic defect, or blindness of both eyes. Villano v. Brown, 10 Vet. App. 248 (1997); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 3.383(a)(1), 4.84a, Diagnostic Codes 6061-6070. Recent examination shows that that the veteran has uncorrected visual acuity of 20/20 of the right eye, corneal scars of the left, and corrected vision of the left to 20/30 on near vision and 20/25 of far vision. Thus, the maximum evaluation for total loss of vision of the left eye is 30 percent. In this case, the Board also notes that there is no evidence of diplopia or visual field deficits. Accordingly, consideration under the provisions of Diagnostic Codes 6080 and 6090 is not warranted. 38 C.F.R. § 4.84a, Diagnostic Codes 6080 and 6090. The preponderance of the evidence establishes that the appellant is not entitled to a rating in excess of 30 percent for aphakia of the left eye. Thus, the benefit-of-the-doubt doctrine is inapplicable, and his claim for an increased rating must be denied. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. § 4.84a, Diagnostic Code 6029. Chronic bilateral ingrown nail of great toes and second left toenail and onychomycosis The veteran asserts that he is entitled to a compensable evaluation for his foot disabilities because the ingrown toenails cause discomfort. After reviewing the evidence pertaining to this matter, the Board finds that an increased rating to 10 percent is warranted for the veteran's foot disabilities. In relevant part, VA regulation provides that unilateral hallux valgus is rated 10 percent disabling where there has been surgery, with resection of the metatarsal head. A 10 percent rating is also for assignment where the hallux valgus is severe, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280 (1999). Diagnostic Code 5279 provides a 10 percent rating for metatarsalgia, anterior (Morton's disease), unilateral, or bilateral. 38 C.F.R. § 4.71a, Diagnostic Code 5279. In the alternative, Diagnostic Code 5283 provides a 10 percent rating for tarsal, or metatarsal bones, malunion of, or nonunion of, which are moderate in degree. A 20 percent rating is assigned when the impairment is moderately large in degree, while the maximum rating of 30 percent is for assignment when the impairment is severe in degree. 38 C.F.R. § 4.71a, Diagnostic Code 5283. Other foot injuries are rated under Diagnostic Code 5284, with the assignment of a 10 percent rating when moderate, 20 percent when moderately severe, or 30 percent when severe. A 40 percent evaluation is in order where there is actual loss of the use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Eczema with ulceration or extensive exfoliation or crusting and systemic or nervous manifestations, or exceptionally repugnant is rated 50 percent disabling; with exudation or itching constant, extensive lesions, or marked disfigurement is rated 30 percent disabling; with exfoliation, exudation or itching, if involving an exposed surface or extensive area is rated 10 percent disabling; with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area is rated 0 percent disabling. 38 C.F.R. § 4.119, Diagnostic Code 7806. In June 1997, after reviewing the veteran's service medical records and April 1997 VA examination report, the RO granted service connection for the veteran's bilateral foot disability and assigned a noncompensable rating. On VA examination in April 1997, the veteran stated that he had problems of the heels and residuals of ingrown toenails. He also complained of pain and stiffness on prolonged standing and walking. Examination revealed no tenderness over either os calcis and the veteran could stand and walk on his heels and toes. However, even though the left great and second toe nails were excised for ingrown nails, the nails were deformed, thickened, discolored, roughened and had grooved debris under the free edges of each nail. Additionally, the great toenail was still ingrown over the medial aspect with chronic inflammatory erythema around the medial embedded edge of the nail. X-ray findings of the feet showed normal soft tissues and bone density for the veteran's age. The alignment of the feet were anatomic without fracture or dislocation, and no joint space narrowing or productive change of noted significance was noted, although a well-corticated rounded fragment of the dorsal to the metatarsophalangeal joint was seen on the left which represented either an ossicle or sequela of old trauma. The diagnosis was residual of partial excision of the left great toe nails times two and complete excision of the second toenail on the left with subsequent deformity of each nail due to onychomycosis with low grade inflammation reaction of the left toe medial aspect due to chronic irritation due to the persistence of the ingrown nail again over the medial aspect of the great toe nail. In light of the foregoing clinical data, the Board finds that entitlement to a 10 percent evaluation is warranted. Clinical findings show that the veteran's foot disability is productive of moderate impairment or, by analogy, exfoliation with exudation or itching. 38 C.F.R. § 4.7, 4.14, 4.20, Part 4, Diagnostic Codes 5284, 7086. The veteran complains of pain and stiffness after prolonged walking and standing and his nails are deformed, thickened, discolored, roughened and have grooved debris under its free edges. Additionally, the great toenail is ingrown over the medial aspect with chronic inflammatory erythema around the medial embedded edge of the nail. As such a 10 percent rating is warranted. Id. The clinical picture associated with the veteran's service- connected disability, however, does not more nearly approximate the criteria required for a rating in excess of 10 percent. Although positive findings of deformed, thickened, discolored, and roughened nails are present, the veteran's foot disability, by analogy, is not productive of eczema with exudation or itching constant, extensive lesions or marked disfigurement, or productive of eczema with ulceration or extensive exfoliation or crusting and systemic or nervous manifestations, or exceptionally repugnant. 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7086. In fact, the veteran has not complained of any constant itching or exudation and no evidence of extensive lesions or marked disfigurement is present. No complaints or findings associated with neurological deficits have been expressed either. Additionally, the veteran's foot disabilities are not productive of moderately severe impairment. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5284. The Board is cognizant of the veteran's complaints of pain and stiffness experienced during prolonged standing and walking. Nonetheless, on recent examination, no evidence of tenderness over either os calcis was noted and the veteran could stand and walk on both heels and toes. Additionally, the veteran has not complained of experiencing any limitation of motion, neurological deficits, excess fatigability, crepitation, atrophy, loss of coordination, or severe deformity associated with his foot disabilities. X-ray findings associated with each foot are essentially normal. The soft tissues are normal, the bone densities are normal for the veteran's age, and the alignment of each foot is anatomic without fracture or dislocation. No evidence of joint space narrowing or significant change is present either. Given the foregoing, the Board finds that the veteran's disability is productive of no more than moderate impairment and entitlement to an increased evaluation in excess of 10 percent is not warranted. 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. Additional matters The Board is cognizant that Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary importance."), is not applicable to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Fenderson v. West, 12 Vet. App. 119 (1999). Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found-a practice known as "staged" ratings. Id. However, after reviewing the evidence of record presented with respect to each matter, the Board finds that the veteran's left eye aphakia disability was not shown to be more than 30 percent disabling during any period when service connection was in effect and that his bilateral foot disability was not shown to be more than 10 percent disabling during any period when service connection was in effect. Additionally, the Board does not find that the issue of extraschedular entitlement under 38 C.F.R. § 3.321(b)(1) (1999) has been raised by the record. The provisions of 38 C.F.R. § 3.321(b)(1) apply when the rating schedule is inadequate to compensate for the average impairment of earning capacity from a particular disability. Here, the veteran has not submitted evidence that his service-connected disabilities affect employability in ways not contemplated by the rating schedule, nor has he submitted any evidence showing that his vision disability or bilateral foot disability impairs earning capacity by requiring frequent hospitalizations or because medication required for those disabilities interfere with employment. Accordingly, the application of the regular schedular standards are not rendered impractical. ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 30 percent for left eye aphakia secondary to penetrating intraocular foreign body with traumatic cataract, lysis of synechia, and corneal adhesion is denied. Entitlement to an initial 10 percent rating for chronic bilateral ingrown nail of the great toes and second left toenail with onychomycosis is granted, subject to the regulations pertinent to the disbursement of monetary funds. WAYNE M. BRAEUER Member, Board of Veterans' Appeals