BVA9504953 DOCKET NO. 93-13 175 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased evaluation for bursitis of the left shoulder, currently rated as 10 percent disabling. 2. Entitlement to service connection for thrombophlebitis. 3. Entitlement to service connection for an eye disorder to include exotropia. 4. Entitlement to service connection for migraine headaches. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Sandra L. Smith, Associate Counsel INTRODUCTION The veteran had active service from September 1977 to October 1984. This appeal is before the Board of Veterans' Appeals (the Board) from a April 1992 rating decision of the Regional Office (RO) which granted service connection and assigned a 10 percent disability rating for bursitis of the left shoulder; but denied service connection for thrombophlebitis, exotropia, and migraine headaches. The case is now ready for appellate review. REMAND The veteran is contending service connection is warranted for his pre-existing esotropia because it was aggravated during his service after he underwent ameliorating surgery in June 1981. The veteran is also contending that service connection is warranted for migraine headaches which he alleged began after the aforementioned eye surgery. After reviewing the evidence on file we conclude that the veteran's claims are potentially well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the claims presented are not inherently implausible. The Board notes that although a congenital or developmental defect is not a "disease or injury" within the meaning of legislation applicable to service connection, service connection may be granted if such a disorder was aggravated by the veteran's active service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. See also O.G.C. Prec. 82-90, 56 Fed. Reg. 45,711 (1990) (Precedent opinion of the General Counsel of the VA). It is also noted that service connection could be in order for intercurrent eye pathology including certain residuals of eye surgery. In addition, VA regulations provide that the usual effects of medical and surgical treatment in service, having the effective of ameliorating diseases or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). A review of the claims folder reveals that the veteran underwent surgery to improve his congenital esotropia while in service in June 1981. Although some service medical records appear to be missing (including the entrance and separation examination reports) the available records show that the veteran did complain of increased eye muscle pain and headaches following the June 1981 surgery. In October 1984, just prior to his discharge from service, the veteran was noted to complain of headaches and to be on medication for "ocular migraine." In addition, a review of the VA medical examination reports, dated in October 1991, reveals that the veteran's complaint of headaches apparently was not addressed by either examiner. The examination report does note that diplopia is present and may be related to the in-service eye surgery. An opinion is needed on this question. In addition, the Board notes that the veteran was not afforded a neurological examination. Furthermore, the Board notes that the veteran submitted copies of VA outpatient treatment records, dated in 1991 and 1992. There is no indication in the claims folder as to whether the RO ascertained whether these records represented the veteran's only treatment at a VA medical facility since his discharge from service. The records on file do reveal some recent evaluations for thrombophlebitis and varicose veins of the left leg. An opinion is needed as to whether the thrombophlebitis is chronic (the veteran was seen for the disorder in service) and whether varicose veins are related to the thrombophlebitis. Finally, the veteran is service connected for a disorder of the left shoulder. It does not appear that the October 1991 examination report contains information concerning all ranges of motion of the shoulder. As the case is otherwise in need of development, an orthopedic examination will be requested. The VA has a duty to assist the veteran in developing pertinent information relating to his claim pursuant to 38 U.S.C.A. § 5107(a) (West 1991). The Court of Veterans Appeals (the Court) has held that the duty to assist also includes providing a thorough and contemporaneous medical examination, which takes into account prior medical evaluations and treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). The Court has also held that when the Board concludes the medical evidence of record is insufficient it may supplement the record by ordering a medical examination. Colvin v. Derwinski, 1 Vet.App. 171 (1991). In light of the above facts, the Board has determined that the case must be REMANDED for the following actions: 1. The RO should attempt to obtain and associate with the claims folder any additional available service medical records, to include the veteran's service entrance and separation examination reports. 2. The RO should obtain and associate with the claims folder all of the veteran's VA medical records, including inpatient and outpatient records, from October 1984 to the present. 3. The veteran should be requested to provide names, addresses, and approximate dates of treatment for all health care providers who have treated him for his alleged service-connected disorders as well as the service-connected bursitis of the left shoulder since his discharge from service. With any necessary authorization from the veteran, the RO should attempt to obtain and associate with the claims file copies of treatment records identified by the veteran. If no records are obtained, the veteran and his representative should be informed of the negative results. 38 C.F.R. § 3.159 (1994). 4. The veteran should be afforded a VA examination by neurology and ophthalmology specialists to determine the nature and severity of any eye and headache pathology. Subjective complaints and objective findings should be legibly recorded in detail. All indicated tests and studies should be conducted. The examiners should state their opinions as to whether the veteran's congenital exotropia increased in severity during service; and if so, whether it was caused by natural progression or the result of the veteran's active service. The examiners should comment as to whether the veteran has any identifiable residuals as a result of the surgery he underwent in service in June 1981, to include diplopia. The examiners should also comment as to the relationship, if any, between the veteran's alleged headaches and his congenital eye disorder and/or the eye surgery performed in June 1981. The claims folder must be made available for review by the medical examiners prior to the examinations to facilitate study of this case. 5. The veteran should be scheduled for a vascular examination of his lower extremities. All indicated tests should be performed and all clinical findings should be reported in detail. The claims folder should be made available to the examiner for review prior to the examination. A determination should be made as to whether there are any indications of continuing of chronic thrombophlebitis, and if so, whether it is related to the in-service episodes. An opinion should also be entered as to whether the veteran has varicose veins of either leg related to the thrombophlebitis, especially the in-service episodes. 6. The veteran should be scheduled for a VA orthopedic examination of the left shoulder. All indicated tests should be performed and all clinical findings should be reported in detail. The claims folder should be made available to the examiner for review prior to the examination. A complete listing of motion in all directions should be set forth. Any atrophy of shoulder girdle muscles, loss of motor strength or other functional limitations observed should be set forth in detail. 7. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. If the claims remain denied, the veteran and his representative should be issued a supplemental statement of the case and they should be afforded the appropriate period of time within which to respond thereto. Then, if otherwise in order, the case should be returned to the Board for further appellate consideration. No action is required of the veteran until he is notified. The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the requested development. MICHAEL D. LYON Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).