BVA9503820 DOCKET NO. 92-15 513 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for ocular histoplasmosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from November 1967 to November 1969 and from August 1981 to September 1989. This appeal arose from an October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The RO affirmed the August 1991 rating decision denying entitlement to service connection for ocular histoplasmosis. The RO again affirmed the previously entered determination when it issued a rating decision in December 1991. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection is warranted for ocular histoplasmosis. He acknowledges that although this eye disorder was already in existence prior to commencement of his second period of active service, had it not been for the excessive strain associated with his military occupational duties, ocular histoplasmosis would not have advanced as quickly as it did thereby resulting in an unusually severe deterioration in his visual acuity. The appellant argues that preexisting ocular histoplasmosis was aggravated by his second period of active service. The representative has requested that the Board provide the veteran with a copy of the opinion of the independent medical expert of record and afford him the opportunity to submit additional evidence. 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 a grant of entitlement to service connection for ocular histoplasmosis. FINDINGS OF FACT 1. Service medical records for the first period of active service are negative for any finding of ocular histoplasmosis. 2. Presumed ocular histoplasmosis syndrome was initially reported by a non-VA health care professional in March 1974. 3. The July 1981 report of medical examination for enlistment shows uncorrected distant visual acuity bilaterally was 20/400; corrected to 20/20 in the right eye, and corrected to 20/200 in the left eye by refraction. 4. An August 1982 eye examination report shows corrected right visual acuity was 20/15; and in the left eye, 20/60+2. 5. A July 1985 general medical examination report shows that uncorrected distant visual acuity in the right eye was 20/200, corrected to 20/20; and in the left eye, 20/400 uncorrected and corrected. 6. A December 1987 eye examination report shows corrected distant visual acuity in the right eye was 20/15+; and in the left eye, 20/50. 7. In November 1994, an independent medical expert in the field of ophthalmology advised the Board that the veteran's preexisting ocular histoplasmosis did not chronically worsen during his second period of active service. CONCLUSIONS OF LAW 1. Ocular histoplasmosis was not incurred in or aggravated by the veteran's first period of active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991). 2. Ocular histoplasmosis, which clearly and unmistakably preexisted the veteran's second period of active service, was not aggravated therein. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(c) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially the Board observes that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that it is at least plausible that his preexisting ocular histoplasmosis was aggravated by his second period of active service. The Board is satisfied that all relevant facts have been properly developed, and that no further assistance to the veteran is required in order to comply with 38 U.S.C.A. § 5107(a). The veteran is of the opinion that service connection for ocular histoplasmosis is warranted because he experienced a more severe deterioration and diminution in his visual acuity solely because of eye strain related to military duties during his second period of active service. However the evidentiary record in this regard is not supportive. In the paragraphs which follow the Board will summarize the clinical history of the veteran's ocular histoplasmosis and show that no basis exists upon which to predicate a grant of entitlement to service connection for histoplasmosis either on the basis of incurrence or aggravation. An October 1965 eye examination conducted at a military medical facility shows uncorrected bilateral visual acuity was reported as 20/20 bilaterally. A March 1967 report of general medical examination for service in the United States Marine Corps shows uncorrected distant visual acuity was 20/200 bilaterally, corrected to 20/20 bilaterally by refraction. The same results were reported when the veteran was examined in January 1968 for Naval Flight Officer training. The report of medical history portion of the examination shows the veteran had worn glasses for ten years. The November 1969 medical examination report for release from active duty shows uncorrected bilateral distant visual acuity was 20/200, corrected to 20/20 bilaterally. On file are the medical records of a non-VA health care professional including a report dated in March 1974. Corrected visual acuity was reported as 20/20 in the right eye, and 10/200 in the left eye. An examination noted that fundus finding was consistent with presumed histoplasmosis syndrome. A May 1975 medical record shows that one year previously the veteran was seen for visual impairment in the left eye diagnosed as histoplasmosis chorioretinitis for which he received laser treatment. Current corrected visual acuity was reported as 20/20 in the right eye, and 20/50 in the left eye. An April 1978 report of general medical examination for enlistment shows bilateral uncorrected distant visual acuity was 20/400; corrected to 20/20 in the right eye, and to 20/30 in the left eye. A July 1980 enlistment examination report shows uncorrected distant visual acuity was 20/400 bilaterally; corrected to 20/20 in the right eye, and to 20/40 in the left eye. A July 1981 private medical report shows an examination of the left eye revealed a large chorioretinal scar with heme inferior to it in the center of the fovea. There were peripapillary changes with some punched out lesions peripherally. The diagnostic impression was presumed ocular histoplasmosis syndrome. A July 1981 report of general medical examination for enlistment shows that uncorrected distant visual acuity bilaterally was 20/400; corrected to 20/20 in the right eye, and to 20/200 in the left eye. An August 1982 eye examination report shows corrected distant visual acuity in the right eye was 20/15; and in the left eye, 20/60+2. A July 1985 over 40 general medical examination report shows that uncorrected distant visual acuity in the right eye was 20/200, corrected to 20/20. Uncorrected and corrected distant visual acuity in the left eye was 20/400. Left histoplasmosis was noted. A December 1987 eye examination report shows that corrected distant right visual acuity was 20/15+; and in the left eye, 20/50. A December 11, 1988 eye examination report from a military medical facility shows corrected right visual acuity was 20/15+, and 20/50 in the left eye. A November 1989 report of general medical examination for enlistment in the Reserves shows that uncorrected right visual acuity was 20/200, corrected to 20/20. Uncorrected left visual acuity was 20/400, corrected to 20/100. An August 1990 report of private eye examination shows that corrected visual acuity in the right eye was 20/60+; and in the left eye, 20/80+. On file is a letter dated in November 1990 from John C. Olson, M.D. Dr. Olson noted that the veteran came under his care during November 1990 for presumed ocular histoplasmosis syndrome, affecting both eyes. He had undergone focal laser treatment in the left eye for subretinal neovascularization fifteen years previously, and required similar treatment in the right eye last September. Dr. Olson noted that subretinal neovascularization associated with ocular histoplasmosis represented activation of a dormant preexisting condition. A December 1990 VA medical certificate shows the veteran had undergone laser surgery in the right eye secondary to histoplasmosis. A February 1991 VA eye examination report shows that bilateral visual acuity without correction was hand movements. In a May 1992 letter, Kenneth B. Miller, M.D., advised that the veteran carried a diagnosis of ocular histoplasmosis. The process appeared to be bilateral. On file is a letter dated in June 1992 from David R. Snydman, M.D. Dr. Snydman noted that the veteran had a history of presumed ocular histoplasmosis diagnosed in 1973 which had been treated with laser surgery in the left eye. Seventeen years later he developed lesions in the right eye constituting a new occurrence of presumed ocular histoplasmosis. On file is a letter to the veteran dated in August 1992 from J. Donald Gass, M.D., of the Bascom Palmer Eye Institute. Dr. Gass referred the appellant to a description of presumed ocular histoplasmosis for which he received treatment at the Institute from 1974 to 1981. In his April 1993 letter to the veteran, Dr. Gass made references to the appellant's treatment and evaluation in 1981 by LLoyd M. Aiello, M.D. Dr. Gass attached an April 1993 letter he had written to Dr. Aiello. In this letter, Dr. Gass made references to a March 1974 photograph of the veteran's left eye which showed evidence of multifocal chorioretinal scars and a juxtafoveal neovascular membrane with subfoveal blood. In May 1975, this neovascular process had extended into the center of the fovea. Dr. Gass went on to note that in July 1981, the veteran had a recurrence of the neovascularization on the nasal side of the left fovea. At that time the right macula was normal. There were slight changes in the pigment epithelium surrounding the optic disc of the right eye. Dr. Gass noted it would appear that changes in both eyes were compatible with the presumed ocular histoplasmosis syndrome. Dr. Gass referenced a December 1987 Air Force eye examination noting a small choroidal lesion nasal to the macular area in the right eye. He stated that whatever was seen was certainly not evident nasally in the right eye at the time of photographs taken in 1981. It was known that a small percentage of patients with the presumed ocular histoplasmosis syndrome would develop evidence of these new scars which probably had been there all along but which were subclinical. In October 1994, the Board decided to undertake additional inquiry concerning the medical question presented in the appellant's case. The Board requested an opinion from an independent medical expert in the field of ophthalmology at a well known medical school. As the contention had been presented that the veteran's second period of active service aggravated his preexisting ocular histoplasmosis thereby causing a rapid and severe deterioration of his vision; particularly, the vision in his left eye, the Board fashioned its inquiry accordingly. The specialist in ophthalmology responded as follows: "I have been asked to respond to the questions of whether the diminution of visual acuity in this applicant's left eye from '20/200 at entrance in service to 20/400 at separation' is an 'expected' consequence of ocular histoplasmosis, or whether this decrease reflected a deterioration 'far beyond what would normally occur' during a period of eight years. First of all, it is not at all clear that the initial premise of visual loss is supportable. The records provided indicate that visual acuity in the left eye measured 20/200 on July 29, 1981 (his pre-induction exam). The next examination was in 1985, at which time acuity was recorded as 20/400 on the left. The difference between 20/200 and 20/400 represents only one line on the conventional Snellan chart, and one line of variability in testing is not unusual at lower acuity levels, given that the test is subjective. With only a single reading of 20/200 at entry, and one 20/400 during his service, this may not constitute a true change in acuity. Vision of 20/200 represents legal blindness, so there is no issue of whether he proceeded to legal blindness during his service. Of greater importance, there is an exam that appears to be from December 11, 1988 (the date is hard to read) which indicates an acuity of 20/50 in the left eye, and an exam of November 17, 1989 that clearly documents an acuity of 20/100 on the left. On August 27, 1990, acuity was recorded as 20/80 in the left eye. These exams show clearly that even if vision fell transiently to 20/400, the evidence shows that there has been no permanent injury or disability at a level worse than his induction exam! Ocular histoplasmosis is a disorder of uncertain infectious or inflammatory etiology that recurs or progresses unpredictably in affected eyes. Individuals who have the disorder may show the development of new lesions, or more seriously, the development of focal subretinal neovascularization. This occurs most often in old scars but may sometimes occur in areas that were not obviously affected before. This patient is known to have had lesions in both eyes, and the natural history is such that he had a risk of reactivation no matter what he did or where he lived. I know of no evidence that military service accelerates this type of disease, nor are any arguments presented as to how or why service could have aggravated the condition. Because the disease leaves scars near the central vision area, central vision may be fragmented and variable, and acuity may decrease or increase as local inflammation comes and goes. Despite having scars near his left fovea, several exams document that this appellant's visual acuity on the left had improved by 1988 to 1990. His left eye may now be his better one since he suffered new disease in the right macula in September, 1990. No specific degree of visual loss is 'an expected consequence' of this disease, but a moderate degree of visual loss in an affected eye is well within the typical range of natural history. Thus this patient's visual loss at the minimum measurable interval of 1 Snellan line is not evidence that there was a deterioration of vision 'far beyond' what might normally be expected for an individual with this disease over an 8-year period. Furthermore, as noted earlier, it is not at all clear that his vision even deteriorated, and the eventual history was one of improvement rather than visual loss. His latest exam on February 1, 1991, which indicated hand-movements in both eyes suggests (but does not document) that he has had new recurrences in both eyes (independent of military service) to account for his present condition. I hope these comments are of use in assessing the appellant's claim. Please contact me if you have questions about these remarks." The Board observes that the response to the question posed to the specialist in ophthalmology is clearly self-explanatory and to the point. The specialist initially questioned the very premise of the Board's inquiry which was framed in terms of assuming that a deterioration in visual acuity had even taken place in service. According to the specialist, not only was there no significant diminution in the veteran's visual acuity in either eye, there was an apparent improvement. The specialist knew of no medical precedent of military service aggravating ocular histoplasmosis and was specific in noting that certainly this did not happen in the veteran's case. The specialist made clear that presumed ocular histoplasmosis is an unusual disease that has its exacerbations and remissions and even noted that visual loss is not an expected consequence. In the veteran's case, visual acuity improved. The hand movements for both eyes reported in 1991 represented an apparent exacerbation or worsening of ocular histoplasmosis, a worsening, as pointed out by the specialist, to have occurred subsequent to service and independent thereof. Overall the specialist expressed the view that there was no aggravation of ocular histoplasmosis and consequent worsening of visual acuity during the veteran's second period of active service which was eight years in duration. It is well to add at this time that the evidentiary record shows that presumed ocular histoplasmosis developed prior to the veteran's second period of active military service. Of this there is no dispute. As to the argument that the second period of active service aggravated this preexisting eye disorder with consequent rapid deterioration of visual acuity in either eye, the Board finds no supportive medical documentation. The only conclusion to be reached in this case is that ocular histoplasmosis was neither incurred in nor aggravated by active service. There exists no basis upon which to predicate a grant of entitlement to service connection. The Board's determination in this regard included consideration of the opinion of an independent medical expert in the field of ophthalmology for the purpose of reaching an informed and balanced determination of the veteran's appeal. For the foregoing reasons the Board concludes that service connection for ocular histoplasmosis is not warranted. 38 U.S.C.A. §§ 1110, 1131, 1153, 5107; 38 C.F.R. § 3.306(c). It is well to point out at this time that a copy of the opinion of the independent medical specialist discussed above was provided to the representative. In this regard, the Board refers the representative to the opinion of the VA General Counsel; namely, VA O.G.C. Advisory Opinion 42-93, dated November 2, 1993. In that opinion it is noted that in cases where appellants are represented, the Board procedure of furnishing a copy of a final independent medical expert opinion only to the representative, as provided in 38 C.F.R. § 20.903, is consistent with the general rule of law, as reflected by Supreme Court precedent, that absent some overriding provision of law, notice to the representative is notice to the claimant. ORDER Entitlement to service connection for ocular histoplasmosis 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.