BVA9506359 DOCKET NO. 92-09 328 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Neil Reiter, Counsel INTRODUCTION The veteran served on active duty during World War II. This matter came before the Board of Veterans' Appeals (the Board) on appeal from a July 1991 rating decision by the St. Petersburg, Florida, Regional Office (RO) which denied entitlement to a total compensation rating by reason of individual unemployability. The Board denied the veteran's claim in May 1993. Subsequently, the veteran filed an appeal with the United States Court of Veterans Appeals (the Court). In July 1993, he submitted a request for reconsideration of the May 1993 decision by the Board. Reconsideration of the May 1993 Board decision was ordered by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991) in November 1993. In December 1993, the Court granted a motion by the Secretary of the Department of Veterans Affairs (VA) for a remand. The Court ordered that the Board's May 1993 decision be vacated. Pursuant to the request for reconsideration, the Board remanded the case in March 1994 for additional development. After such development was accomplished, a supplemental statement of the case was issued. The case was then returned to the Board for its consideration. The case will now be decided by an enlarged panel of the Board consisting of members who did not review the previous decision of May 1993. The present decision by the enlarged panel will be based on a de novo review of the record and will replace the decision of May 1993. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that his various service- connected disabilities prevent him from obtaining and pursuing gainful employment. He contends that he is severely disabled as the result of the loss of vision, arteriosclerotic heart disease with angina, and diabetes mellitus, and that the symptoms and manifestations of these and his other disabilities prevent him from working. DECISION OF THE BOARD The 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 files. 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 veteran is entitled to a total compensation rating by reason of individual unemployability. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the regional office. 2. The veteran has been granted service connection for bilateral aphakia, evaluated as 50 percent disabling; for diabetes mellitus, evaluated as 20 percent disabling from May 24, 1977, and 40 percent disabling from October 8, 1992; for arteriosclerotic heart disease, evaluated as 30 percent disabling; for epidermophytosis of the feet, evaluated as 10 percent disabling; and for arthralgia of the knees, bilateral pes planus, and bilateral varicose veins, each of which are noncompensable. 3. A combined evaluation of 80 percent has been in effect since December 29, 1989, and the veteran has been found entitled to special monthly compensation benefits on account of the loss of use of one eye, with light perception only. 4. The veteran worked as a lawyer for many years. 5. In combination, the symptoms and manifestations of the veteran's service-connected disabilities prevent him from obtaining and pursuing gainful employment. CONCLUSION OF LAW The criteria for a total compensation rating by reason of individual unemployability have been met. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 4.16, 3.340, 3.341 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). The Board is also satisfied that all relevant information has been obtained to adjudicate the present claim. I. Background The veteran has been granted service connection for bilateral aphakia, evaluated as 50 percent disabling; for diabetes mellitus, evaluated as 20 percent disabling from May 24, 1977, and 40 percent disabling from October 8, 1992 (when the rating was expanded to include diabetic neuropathy and neurogenic bladder); for arteriosclerotic heart disease, evaluated as 30 percent disabling; for epidermophytosis of the feet, evaluated as 10 percent disabling; and for arthralgia of the knees, bilateral pes planus, and bilateral varicose veins, each of which are evaluated as noncompensable. A combined evaluation of 80 percent has been in effect from December 29, 1989. The veteran has also been found entitled to special monthly compensation benefits on account of the loss of use of one eye, with only light perception, effective from September 9, 1991. The veteran worked as a lawyer for many years. He reported that he last worked in 1979. On an application for increased compensation based on unemployability received in June 1991, the veteran reported that he was unable to do the required reading and research for the occupation of lawyer because of his visual disability. Physicians statements dated in September 1991 and October 1991 indicate that the veteran had a corneal transplant in May 1988 in the left eye, and that in September 1991 he was seen in emergency consultation for a sudden loss of vision in the left eye. It was indicated that he had a severe corneal graft rejection in this left eye and that he would be placed on medication. In November 1991, his physician reported that vision in the left eye was only finger counting, and that he might never have useful vision in this eye. On a VA eye examination in November 1991, the veteran reported that he had very poor vision in his left eye, and that he had difficulty reading because his eyes would water and blur easily. His history showed that he had had cataract extraction in the right eye in 1974 and in the left eye in 1976. There was removal of the intraocular lens in the left eye in 1979 and a corneal transplant in 1989. Repeated grafts had failed. He reported that he had diabetes mellitus for about 40 years, and that this disability was under fair control with oral medication. On examination, there was bilateral aphakia with posterior chamber lenses. Uncorrected vision in the right eye was 20/40, with correction to 20/20 with a lens. The left eye showed light perception only. The diagnostic impression was bilateral aphakia with corneal graft of the left eye following corneal decompensation. The examiner expressed the opinion that the visual acuity of light perception only in the left eye would not improve. The veteran submitted copies of medical reports relating to his visual acuity in 1986 and 1987. VA outpatient treatment reports for 1992 and early 1993 were received showing that the veteran was seen for urinary tract infections and other problems. Clinical tests resulted in the diagnostic impression of diabetic neuropathy causing hypotonic neurogenic bladder. He was also seen in the eye and dermatology clinics. A dermatology evaluation in April 1993 showed a satisfactory evaluation. A private physician in September 1993 reported that the veteran had had a repeat corneal transplant of the left eye approximately six months previously and had rejection of the graft, resulting in no vision in that eye. On a special VA urology examination in October 1993, the veteran reported minimal urinary tract symptoms. He described 1 or 2 times a night nocturia, with mild hesitancy and mild nocturnal incontinence. Rectal examination was normal. On a VA general medical examination in November 1993, the veteran reported that his medications included insulin, 70/30, 7.5 units twice a day, Ibuprofen, 400 milligrams, twice a day, and Tylenol. On physical examination, he weighed 137 pounds and he was 5 feet 4 inches tall. There were two ecchymotic areas on the dorsum of the left forearm and an 8-centimeter soft subcutaneous nodule on the right side of the neck. There were no other skin abnormalities. Examinations of the respiratory and cardiovascular systems were normal. Blood pressure was 182/76. Diagnoses included insulin-dependent diabetes mellitus with neuropathy involving both legs (history); hypotonic neurogenic bladder (history); arteriosclerotic heart disease (history); varicose veins (history); and subcutaneous lipoma of the right side of the neck (history). Clinical records from the Cleveland Clinic in Fort Lauderdale, Florida, for 1992 and 1993 were received. Laboratory studies in February 1993 and May 1993 showed that glycohemoglobin was slightly elevated. Hemoglobin and hematocrit in October 1992 were within normal limits. The veteran reported in February 1993 that fasting blood sugar was generally within normal limits. He was instructed to increase the protein and decrease the carbohydrates in his diet. VA outpatient reports for 1993 and 1994 show that in May 1993 the veteran reported a hypoglycemic reaction. He reported no other complaints, including no shortness of breath or angina. In 1994, the veteran reported some occasional angina. He reported that he carried nitroglycerin, but rarely needed to use these pills. On a special VA cardiology examination in May 1994, the veteran reported occasional angina syndrome, noting that he felt comfortable at rest. He reported one block shortness of breath and experiencing anginal chest pain while walking faster or walking beyond one block. He also stated that he had experienced cardiac palpitations and dizzy spells. He reported a syncope episode about three years ago. He took enteric coated aspirin once a day and sublingual nitroglycerin when needed. On physical examination, blood pressure was 130/80. He weighed 145 pounds. The chest and lungs were clear to auscultation and percussion. Cardiac examination revealed regular rhythm. There was a Grade I/VI systolic murmur at the apex, and the left ventricular impulse was displayed laterally, suggestive of left ventricular enlargement. There was no pitting edema. Pulses were decreased in the legs. An electrocardiogram performed in March 1994 was interpreted as showing sinus rhythm with a rate of 60 per minute, first degree atrioventricular block, and right bundle-branch block. A follow- up electrocardiogram in April 1994 showed the disappearance of the right bundle-branch block. Urinalysis in April 1994 was negative for glucose. A chest X-ray in May 1994 revealed left ventricular prominence, indicative of slight left ventricular enlargement. A Doppler echocardiogram in May 1994 showed some thickening of the mitral valve, prolapse of the posterior mitral valve, and mild mitral regurgitation. There was left atrial enlargement. There was trace tricuspid valve regurgitation, and trace pulmonary valve regurgitation. There was some indication of diastolic dysfunction. The diagnostic assessments were arteriosclerotic heart disease, and mitral valve prolapse with mild mitral regurgitation. The patient's cardiac disability was compatible with Class II and Class III. On a VA eye examination in May 1994, corrected visual acuity in the right eye was 20/25 and corrected visual acuity in the left eye was counting fingers at 5 feet. He improved with pinhole to 20/200, but did not improve with refraction. The diagnostic impression was status post cataract extraction with intraocular lenses implanted, status post penetrating keratoplasty in the left eye with corneal decompensation. He also had background diabetic retinopathy in the right eye. On a special orthopedic examination in May 1994, the veteran reported pain in both legs, worse at night than during the day. On physical examination, he had a satisfactory gait. Examination of the knees showed no evidence of effusion or ligamentous instability. There was some crepitus. Examination of the lower extremities showed a 1- to 2-plus pitting edema of both ankles. X-rays of the knees showed degenerative changes. The clinical impression was that of a chronic peripheral neuropathy secondary to diabetes mellitus, and mild chondromalacia. On a special examination for diabetes in May 1994, the veteran denied symptoms of diabetic neuropathy, as he had no complaints of pain, burning, or tingling sensations. He denied claudication, chest pain, or shortness of breath. He indicated that he believed that his diabetes was well controlled. He reported averaging between 130 to 138 blood sugars, without any symptoms of hypoglycemia. He reported taking insulin, 7 units in the morning and 5 units at dinner. Physical examination revealed evidence of previous ocular surgery, a heart murmur, and changes consistent with peripheral vascular disease in the lower extremities. It was believed that his diabetes mellitus was well controlled. II. Analysis The Board has reviewed the evidence of record concerning the veteran's adaptability for employment, considering the nature, extent, and history of his service-connected disabilities. In this regard, it is noted that he has been granted a 50 percent evaluation for bilateral aphakia, a 40 percent evaluation for diabetes mellitus with diabetic neuropathy and neurogenic bladder, a 30 percent evaluation for arteriosclerotic heart disease, a 10 percent evaluation for epidermophytosis of the feet, and noncompensable evaluations for arthralgia of the knees, bilateral pes planus, and bilateral varicose veins. The Board has reviewed the various VA examinations, VA outpatient treatment reports, and reports from his private physicians. These examinations show that the veteran's ocular problems in the left eye have not responded to repeated efforts at implants. He has little vision in his left eye; and normal visual acuity of the right eye. He has stated on examination that he does have eye strain when reading, with watering of the eyes. This would prevent him from reading or performing other arduous visual tasks for any lengthy period of time. His diabetes mellitus is generally under good control, although he has peripheral neuropathy, a neurogenic bladder, and pitting edema in the lower extremities. On recent VA examinations, clinical studies showed some multiple symptomatology indicative of cardiac enlargement, valvular regurgitation, and diastolic dysfunction. The veteran described some problems with angina and shortness of breath with mild exercise, and it appears that the service-connected arteriosclerotic heart disease, which was classified as II or III, is causing increasing physical limitations. Objectively, reviewing the current manifestations of the veteran's various disabilities, the Board believes that the symptoms and manifestations of the veteran's service-connected disabilities, in combination, now prevent him from engaging in gainful employment, regardless of age. The veteran is becoming more physically disabled as the result of his arteriosclerotic heart disease, diabetes mellitus, and ocular problems. He certainly is unable to perform activities involving any strenuous exercise, and even sedentary employment is precluded because of the various symptoms and manifestations of his service-connected disabilities. Consequently, he is entitled to a total compensation rating by reason of individual unemployability. 38 C.F.R. §§ 4.16, 3.340, 3.341. The benefit of the doubt has been resolved in his favor. 38 U.S.C.A. § 5107. ORDER Entitlement to a total compensation rating by reason of individual unemployability is established. The benefit sought on appeal is granted, subject to the controlling regulations for the award of monetary benefits. STEPHEN L. WILKINS JAMES R. ANTHONY Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals WAYNE M. BRAEUER Member, Board of Veterans' Appeals JACQUELINE E. MONROE BARBARA B. COPELAND Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals CHARLES E. HOGEBOOM Member, Board of Veterans' Appeals 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.