BVA9508193 DOCKET NO. 90-20 538 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUE Entitlement to service connection for bilateral eye disorder. REPRESENTATION Appellant represented by: Blinded Veterans Association WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James A. Frost, Associate Counsel INTRODUCTION The veteran served on active duty from February 1941 to November 1945 and from August 1946 to September 1953. This appeal initially arose from a rating decision in March 1989 by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The Board of Veterans' Appeals (the Board) notes that a rating decision in December 1965 denied entitlement to service connection for an eye disorder. The veteran was duly notified of the decision; he did not file a timely substantive appeal and the decision became final. Thereafter, he submitted additional evidence, including testimony at a personal hearing in April 1990, in an attempt to reopen his claim. In a decision of November 14, 1991, the Board found that new and material evidence had not been presented or secured which would warrant reopening the claim. Thereafter, the veteran appealed the Board's decision to the United States Court of Veterans Appeals (Court), which, upon a joint motion by the Secretary of Veterans Affairs and the veteran-appellant, vacated the Board's November 14, 1991, decision and remanded the case to the Board for further proceedings. [citation redacted]. In January 1994 the Board remanded the case to the RO for a VA ophthalmological examination. The case was returned to the Board in April 1994. In October 1994 the Board requested a medical opinion from an independent medical expert (IME), a professor and chairman of the department of ophthalmology at a leading medical school. The IME's opinion was received in January 1995. An opportunity was provided to the veteran's representative to present additional evidence and argument in response to the IME's opinion. The representative responded in March 1995. The case is now ready for further appellate review. Upon further consideration, the Board finds that the additional evidence submitted since the last decision on the merits of the claim in 1965 is new and material and warrants reopening the claim. The Board will therefore consider the veteran's claim of entitlement to service connection for bilateral eye disorder on a de novo basis. The veteran will in no way be prejudiced by such action, as he has, since he attempted to reopen his claim in December 1988, been presenting evidence and arguments on the merits of the service connection claim. Bernard v. Brown, 4 Vet.App. 384 (1993). CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that ocular histoplasmosis, first found years after service, was the result of exposure to histoplasmosis fungus during his period of active service. In the alternative, he contends that tonsillitis or gallbladder disease in service may have been symptoms of histoplasmosis or that a skin inflammation and headaches may have been caused by histoplasmosis fungus. 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 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 veteran's claim. FINDINGS OF FACT 1. Ocular histoplasmosis was not present in service or until years thereafter, nor is it attributable to any incident or manifestation in service. 2. An independent medical expert, who reviewed the veteran's medical records, found that he did not contract ocular histoplasmosis during his period of active service. CONCLUSION OF LAW A bilateral eye disorder was not due to injury or disease incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107; 38 C.F.R. § 3.303 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board notes that the veteran's claim is "well- grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a). Service medical records disclose that the veteran sustained trauma to both eyes in service. Foreign bodies were removed from his right eye in 1945 and 1948 and from his left eye in 1952. Also, in 1952 he was treated for conjunctivitis of the left eye. At a medical examination for service separation in 1953 the veteran did not report a problem with his eyes, which were evaluated as normal. The service medical records also show treatment for impetigo during the veteran's first period of active service, treatment for tonsillitis in late 1944, complaints of headaches during the veteran's second period of service and cholecystitis, with calculi, which resulted in a cholecystectomy in October 1951. In April 1957 the veteran asserted his original claim of entitlement to VA compensation or pension. He made no reference to his eyes. In November 1965 Jack D. Weaver, M.D., private ophthalmologist, reported that at an examination in March 1964 vision in the veteran's right eye was 2/200, which could not be improved; vision in the left eye was 20/15. The right eye had an old quiescent chorioretinic scar which had obliterated the cecocentral area. In May 1971 James T. Robinson, M.D., reported that he had examined the veteran's eyes in September 1970. Visual acuity was finger counting at 2 feet in the right eye and less than 20/400 in the left eye. On examination macular elevation, peripapillary scarring and peripheral punched-out areas were observed, bilaterally. The diagnosis was chorioretinitis. At a VA eye clinic in May 1971, the veteran gave a history of loss of vision in the right eye since 1960 and in the left eye since 1970. Visual acuity was 2/200 in the right eye and 4/200 in the left eye, which could not be corrected. The diagnosis was chorioretinitis, left eye, still active. The prognosis was negative for recovery of sight. In a letter to the RO, received in November 1972, the veteran stated that during service an Army surgeon had told him and others that all persons serving in Korea would probably be affected by some disease endemic to that country. He also said that Dr. Robinson and another physician had told him that it was impossible to determine when a person had contracted retinitis. In September 1978 at a VA eye clinic the veteran gave a history of poor vision in the right eye since 1960 and in the left eye since about 1970. Visual acuity was 3/200 in the right eye and 4/200 in the left eye. An examination revealed pigmentary macular degeneration in both eyes. In January 1979 the veteran was admitted to a VA medical center for blind rehabilitation. The diagnosis was decreased vision secondary to ophthalmic histoplasmosis. In a statement received at the RO in August 1979 the veteran stated that a diagnosis of retinitis pigmentosa by a private physician in 1964 had been changed to a diagnosis of histoplasmosis by the VA Blind Center in 1979. He stated, "I feel this condition may have begun while I was on active military duty while serving in the Philippines, Japan and Korea, due to unsanitary conditions which seemed to be the cause of this." In February 1989 the National Personnel Records Center reported to the RO that no records from the Office of the Army Surgeon General were available in the veteran's case. In a statement received at the RO in February 1990 the veteran said that in service "in either 1953 (sic) or 1953" he had to get corrected lenses, and he believed that later-diagnosed histoplasmosis was present at that time; he served in Japan, Korea and the Philippines, all of which are countries noted for unsanitary living conditions; he first discovered trouble with his right eye in 1960 and with his left eye in 1970. At a personal hearing in April 1990 the veteran testified that: Foreign bodies were removed from his eyes in service, and he was treated for conjunctivitis; in 1952 or 1953 his last assignment was at Fort Benjamin Harrison, Indiana, where his glasses were changed for "an eye problem"; he first noticed a vision problem in his right eye in 1960, but he didn't see a physician until 1964, when a diagnosis of retinitis pigmentosa was made; in 1979 at Hines VA Medical Center in Illinois, the diagnosis was changed to histoplasmosis; it was his understanding that histoplasmosis was a fungus disease of the eyes, probably caused by bird droppings, which was common in the Far East and the Ohio Valley of the continental United States. He testified further that: He had not had histoplasmosis of anything besides his eyes; specifically, he had not had lung disease; in 1960 vision in his right eye became blurred and he gradually lost sight in that eye. In August and September 1990 the veteran was a patient at a VA medical center for blind rehabilitation. The diagnosis was blindness secondary to ocular histoplasmosis. In February 1991 the veteran's representative asserted that a medical treatise showed histoplasmosis to be endemic to the countries where the veteran had served and to the Ohio, Missouri and Mississippi River Valleys of the continental United States. A VA eye examination in March 1991 yielded a diagnosis of healed chorioretinitis, bilateral, probably of histoplasmosis origin. In a statement filed with the Court in March 1992, the veteran asserted that his eye problems started in service at his last duty station, Fort Harrison, Indiana, which is in the Ohio Valley, where histoplasmosis is prevalent, or before then, in Korea, Japan and the Philippines, which had poor sanitation systems. The veteran stated that a person who loses his sight in one eye at the time cannot say when he lost the sight of the first eye, because the other eye gradually adjusts to the loss, and no ophthalmologist will say when histoplasmosis began. In January 1994, the Board remanded the veteran's case to the RO for an ophthalmological examination. The examiner offered an opinion that removal of foreign bodies from the veteran's eyes and conjunctivitis in service are "of no meaning" in his present ophthalmic condition. The examiner found that the veteran's loss of vision in each eye was due to histoplasmosis, but he offered no opinion as to the time of onset of histoplasmosis. The Board then referred the veteran's claims file to an independent medical expert (IME), a professor and the chairman of the department of ophthalmology at a medical school. The IME was asked to offer an opinion on the question of whether the veteran's current eye pathology is etiologically related to trauma or disease of the eyes during his periods of active service. The IME's opinion is of record. The IME stated that the veteran's loss of vision is not related to removal of foreign bodies or conjunctivitis in service; the service medical records show that his bilateral visual acuity was normal after the foreign bodies were removed and the conjunctivitis resolved. The IME stated that, after a primary infection of presumed ocular histoplasmosis syndrome heals, calcific granulomas may be left in the lungs or hilar nodes. A chest X-ray of the veteran in September 1951 reported no granulomas. The IME stated that an inquiry must be made as to whether the veteran was exposed to the fungus histoplasus capsulatum between the chest X-ray in 1951 and his discharge in 1953. A definitive diagnosis would require a demonstration of the organism by culture or histology. Such an infection may be asymptomatic or very mild, and might not be associated with pulmonary X-ray findings. The veteran's native state of Kansas has a high proportion of people with positive histoplasmin sensitivity. Systemic symptoms of histoplasmosis include cough, fever, malaise and chest X-ray findings of hilar adenopathy. The IME stated that he had carefully reviewed the veteran's records and there was no evidence to support a finding that the veteran obtained the histoplasmosis organism in service. The IME concluded that the veteran's eye pathology was not related to trauma or disease in service. Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 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, or, if preexisting such service, was aggravated therein. Each disabling condition shown by a veteran's service records, for which he seeks service connection, must be considered on the basis of the places, types and circumstances of his service, 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 VA's policy 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 medical questions for consideration in this case are whether the veteran's eye disorder, which was caused by ocular histoplasmosis, was either manifested in service or the result of infection by histoplasma capsulatum during his periods of active service. The veteran's representative has asserted that, at an eye examination in September 1951, a visual field chart showed "severe" restriction of the visual fields, which may have been an indication that the veteran had incurred eye disease. However, the Board notes that the report of that examination contains a notation "normal fields," with a slight enlargement of the left physiologic blind spot. As noted above, the examination for service separation in September 1953 showed no problem with the eyes or vision, and the Board therefore cannot accept the representative's interpretation of the 1951 visual field chart. With reference to the question of whether histoplasmosis was manifested in service, the Board notes that the IME answered this question in the negative and that the veteran and his representative have cited no medical authority for their theory that headaches or impetigo may have been caused by the histoplasmosis fungus. Lay persons, such as the veteran and his representative, are not competent to offer opinions on questions of medical diagnosis or medical causation. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Similarly, no competent medical evidence has been submitted to demonstrate that tonsillitis or cholecystitis were manifestations of an infection by the histoplasmosis organism. The IME specifically found no support for the claim that symptoms of histoplasmosis, such as respiratory symptoms or gastrointestinal symptoms, were manifested in service. In the absence of any competent medical evidence contrary to the IME's opinion, the Board will accept the IME's finding that histoplasmosis was not manifested by symptomatology during the veteran's periods of active service. With reference to the question of whether the veteran was exposed to histoplasma capsulatum in service, the IME stated that the fungus is indeed present in Indiana and the Far East, where the veteran served. However, it is also present in the veteran's native state of Kansas, where he lived before service and after service. The IME found that the mere physical presence of an individual in areas where histoplasmosis fungus is found does not show that the disease of ocular histoplasmosis was contracted at any specific time. The Board is thus unable to find that the veteran was infected by histoplasmosis fungus during service, rather than prior to service or after service. The Board finds that the preponderance of the evidence does not show that the veteran contracted ocular histoplasmosis in service. His bilateral eye disorder is, the Board finds, not of service origin. The Board has considered the time, places and circumstances of the veteran's service. Service connection for a bilateral eye disorder is not established. 38 U.S.C.A. §§ 1110, 1131, 1154; 38 C.F.R. § 3.303. While the Board has considered the doctrine of affording the veteran the benefit of any existing doubt with regard to the issue on appeal, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant resolution of this matter on that basis. 38 U.S.C.A. § 5107(b). ORDER Service connection for a bilateral eye disorder is denied. ALBERT D. TUTERA 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. 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.