Citation Nr: 0003521 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 98-08 684A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for ptosis, bilateral, with corrective surgery. 2. Entitlement to service connection for arthritic problems. 3. Entitlement to service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. Pomeranz, Associate Counsel INTRODUCTION The appellant served on active duty from August 1963 to August 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 1997 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Oakland, California. The Board notes that in the appellant's June 1998 substantive appeal, the appellant raised the issue of entitlement to service connection for cataracts. This issue has not been developed for appellate consideration and is referred to the RO for appropriate action. FINDINGS OF FACT 1. The claim of entitlement to service connection for ptosis, bilateral, with corrective surgery, is supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim of entitlement to service connection for arthritic problems is supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 3. There is no competent medical evidence of a nexus between any recurrent iritis, secondary to rheumatoid arthritis, HLA- B27 positive uveitis in the right eye, and the appellant's period of active service. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for ptosis, bilateral, with corrective surgery is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for arthritic problems is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The appellant's claim for service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye, is not well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Entitlement to service connection for (1) ptosis, bilateral, with corrective surgery, and (2) arthritic problems. I. Factual Background The appellant's service medical records show that in January 1964, the appellant was diagnosed with bilateral ptosis and subsequently underwent corrective surgery. Following his surgery, it was noted that the appellant's corneas were markedly improved. The records reflect that in April 1964, the appellant was diagnosed with male Turner's syndrome, otherwise known as Noonan's syndrome. In June 1965, it was noted that the appellant's Turner's syndrome was a congenital syndrome with numerous symptoms, including low set ears, bilateral ptosis, and short broad hands and digits. According to the records, in March 1981, the appellant was treated after complaining of pain in his neck, right hip, and lower back. At that time, he stated that he had stiffness in his neck and in the joints of his left arm and fingers, with weakness in his left hand and left leg. The appellant noted that he had recently recovered from the flu. The physical examination showed that the appellant's neck was supple except for a "wobbled neck." The appellant flexed his neck without any difficulty. There was tenderness in the T-1 area, up to T-6. The assessment was of pain in the thoracic spine and left hip, with degenerative joint disease. The service medical records show that in June 1982, the appellant was treated after complaining of drooping lids over the past year. At that time, he gave a history of Noonan's syndrome with ptosis. The appellant stated that he was status-post ptosis surgery in 1967. The physical examination shows that the appellant's pupils were 3/3, and there was no Marcus Gunn. It was noted that the appellant used frontalis for lid elevation. The assessment was of Noonan's syndrome. The examining physician noted that the appellant's ptosis was a problem, and that the appellant's very best visual acuity, in both eyes, was 20/40. The records reflect that in May 1982, the appellant requested that his prescription for Motrin be refilled. At that time, he stated that he used the Motrin for "arthritis" in his shoulders. According to the records, in August 1982, the appellant underwent surgery for his bilateral ptosis. At that time, he gave a history of his male Turner's syndrome, which was marked by high hyperopia, cryptorchism, and ptosis. The appellant indicated that he had undergone surgery for his ptosis in 1966, and that at present, he had falling lids in both eyes. He requested surgical correction of his falling lids. Thus, in August 1982, the appellant underwent a bilateral frontalis sling procedure. Following the surgery, he was diagnosed with bilateral ptosis. The appellant's separation examination, dated in August 1983, shows that at that time, in response to the question as to whether the appellant had ever had or if he currently had, swollen or painful joints, eye trouble, arthritis, rheumatism, or bursitis, the appellant responded "yes." At that time, the appellant stated that he had pain in his left leg and back due to arthritis. The examining physician noted that the appellant had undergone surgery in order to have his eye lids raised. The examiner further indicated that the appellant had male Turner's syndrome, which included ptosis, and a history of arthritis in his left leg and back. The appellant's eyes were clinically evaluated as abnormal. The examiner further indicated that the appellant had joint pain in his left leg and back. In September 1984, the appellant underwent a VA examination. At that time, he stated that he had male Turner's syndrome and ptosis of the eyelids. The appellant indicated that he had had two surgeries in order to correct his drooping eyelids. The examining physician noted that upon a review of the record, the appellant was prone to "various orthopedic and arthritic complaints." The appellant stated that at present, he had neck pain and occasional aches involving his hands, lower back, right hip, and his right knee. He reported that his shoulders also bothered him. The physical examination showed that the appellant's pupils were equal, round, and reactive to light and accommodation (PERRLA), and his extraocular muscles were intact. There did not appear to be any "greatly noticeable ptosis of the eyelids." Examination of the shoulders revealed no external deformity, and the appellant exhibited a full range of motion. Elevation was to 80 degrees, abduction was to 180 degrees, internal rotation was to 90 degrees, and external rotation was to 90 degrees. There was no limitation of range of motion of the cervical spine. The diagnoses included the following: (1) Noonan's syndrome, male Turner's syndrome, (2) orthopedic problems secondary to Noonan's syndrome, subjectively involving the appellant's cervical spine and right shoulder, and to a lesser extent, the appellant's low back, hands, right knee, and right hip, and (3) history of operation for ptosis, secondary to Noonan's syndrome. In the appellant's September 1984 VA examination, x-rays were taken of his right shoulder and cervical spine. The x-ray of his right shoulder was interpreted as showing no joint calcification, fracture, dislocation, or focal bony lesions. The impression was of a normal right shoulder. The x-ray of his cervical spine was interpreted as showing small anterior osteophytes in the lower cervical spine, with minimal disc space narrowing at C4-5, C5-6, and C6-7. No other abnormalities were seen. The impression was of minimal osteophytosis and disc space narrowing, lower cervical spine, consistent with degenerative changes. In November 1984, the RO received x-rays from the VA Medical Center (VAMC) in San Francisco, dated in August 1984. An x- ray of the appellant's chest was interpreted as showing mild demineralization of the thoracic spine. There was a mild scoliosis with concavity to the left. The impression was of demineralization and degenerative changes of the thoracic spine, as described above. An x-ray of the appellant's right shoulder was reported to be within normal limits. An x-ray of the appellant's cervical spine was interpreted as showing disc space narrowing at C4-5 and C6-7, which was minimal, and no associated osteophytes were seen. Outpatient treatment records from the Silas B. Hays Army Community Hospital, from December 1983 to November 1993, show that in January 1984, an x-ray was taken of the appellant's cervical spine. The x-ray was interpreted as showing disc space narrowing at the C4-5, C5-6, and C6-7 level. Anterior osteophytes were identified at C5-6 and C6-7. Uncinate process hypertrophy was identified at C6 and C7, which were consistent with degenerative disc changes. The records reflect that in April 1987, the appellant had an x-ray taken of his cervical spine. At that time, the x-ray was interpreted as showing marked degenerative changes of the mid and lower cervical spine. Disc space narrowing was seen at C4-5, C5-6, and C6-7. Intervertebral foraminal encroachment was seen bilaterally at C5-6 and C6-7. The degree of the degenerative changes was very similar. The impression was of degenerative changes of the cervical spine. According to the records, in January 1990, the appellant had an x-ray taken of his lumbosacral spine. At that time, the x-ray was interpreted as showing normal disc spaces and vertebral body heights. There appeared to be a squaring of the vertebral bodies along with early osteophyte formation, which could have possibly represented degenerative changes, but could have also represented ankylosing spondylitis. The remainder of the lumbar spine was unremarkable. The Silas B. Hays Army Community Hospital records reflect that in May 1990, the appellant had a computed tomography (CT) scan of the cervical spine. At that time, the impression was of mild degenerative changes of the cervical spine, with slight bony encroachment on the right at approximately the C6-C7 level, upon the subarticular canal. There was no definite herniated nor bulging disc material. The records also reflect that in June 1991, the appellant had a CT scan of the mid and lower lumbar spine. The impression was of degenerative disease of the left facet joint at the L5-S1 level, with mild encroachment upon the left subarticular canal. According to the records, in July 1991, the appellant had a CT scan of the cervical spine. At that time, the impression was of mild degenerative changes of the cervical spine, with no bony encroachment upon the spinal canal, nor upon the intervertebral foramina. The records from the Silas B. Hays Army Community Hospital show that in August 1991, an x-ray was taken of the appellant's lumbosacral spine. The impression was of disc narrowing at L5-S1. The records reflect that in October 1991, the appellant had a second CT scan taken of his lumbar spine. At that time, the scan was interpreted as showing hypertrophic spur formation along the anterior portion of the L3-L4 vertebra bodies. There was sclerosis and hypertrophic new bone formation along the margins of the apophyseal joints between L3-L4, between L4-L5, and between L5-S1. There was no significant spinal stenosis. According to the records, the appellant also had an x-ray taken of his left shoulder which was interpreted as showing a coracoclavicular bony projection, with the formation of a relative joint space between the projection and the coracoid process of the scapula. The acromioclavicular joint space appeared radiographically benign. The records further reflect that the appellant had an x-ray taken of his hands. The x-ray was interpreted as showing that the majority of the distal interphalangeal joint spaces demonstrated a mild degree of narrowing, with small marginal osteophytes. The osteophytes were associated with slight radical deviations involving the distal interphalangeal joint spaces of the left second and fifth digits, and the right fifth digit. The appearance was consistent with osteoarthritic changes. A private medical statement from E.J.K., M.D., dated in April 1993, shows that at that time, the appellant was treated after complaining of pain in his left shoulder and back. At that time, the appellant noted that he had recently been involved in an automobile accident and that following the accident, he developed pain in his chest and arm. The impression was of a cervical strain syndrome, with contusion of the chest and lateral ribs. In November 1995, the RO received additional service medical records for the appellant. The additional records show intermittent treatment for the appellant's male Turner syndrome. II. Analysis The Board notes that a review of the record reflects that the appellant has been diagnosed with Noonan's syndrome, as shown by the September 1984 VA examination. In addition, the Board further observes that it appears that the appellant was first diagnosed with Noonan's syndrome during service. According to the appellant's service medical records, the appellant's enlistment examination, dated in August 1963, is negative for any complaints or findings of Noonan's syndrome. Moreover, in April 1964, the appellant was diagnosed with male Turner's syndrome, otherwise known as Noonan's syndrome. The appellant's service medical records further reflect that in June 1965, it was noted that the appellant's Turner's syndrome was a congenital syndrome with numerous symptoms, including ptosis. The records also show that the appellant underwent surgery for his ptosis twice, first in 1964 and again in August 1982. Moreover, according to the records, the appellant sought intermittent treatment for arthritic complaints. As previously stated, in the appellant's September 1984 VA examination, the appellant was diagnosed with Noonan's syndrome. At that time, the appellant was also diagnosed with the following: (1) orthopedic problems secondary to Noonan's syndrome, subjectively involving the appellant's cervical spine and right shoulder, and to a lesser extent, the appellant's low back, hands, right knee, and right hip, and (2) history of operation for ptosis, secondary to Noonan's syndrome. In addition, the evidence of record shows that the appellant has been diagnosed with numerous arthritic conditions including the following: (1) demineralization and degenerative changes of the thoracic spine, (2) minimal osteophytosis and disc space narrowing of the lower cervical spine, consistent with degenerative changes, (3) disc space narrowing at the C4-5, C5-6, and C6-7 level, and (4) degenerative disease of the left facet joint at the L5-S1 level, with mild encroachement upon the left subarticular canal. The Board observes that in light of the above, the appellant has presented evidence of a current diagnosis of Noonan's syndrome, which is a congenital syndrome. The Board further notes that the evidence of record suggests that the appellant's Noonan's syndrome was aggravated by service. The appellant was originally diagnosed with Noonan's syndrome during service. In addition, while he was in the military, he underwent two operations for his bilateral ptosis, and he sought intermittent treatment for arthritic complaints. The Board further notes that in the appellant's September 1984 VA examination, he was diagnosed with orthopedic problems secondary to Noonan's syndrome and a history of operation for ptosis, secondary to Noonan's syndrome. In regards to the appellant's orthopedic problems, it is the Board's determination that the evidence of record suggests that the appellant's orthopedic problems include his arthritic conditions. Therefore, since there is evidence sufficient to lend plausible support to the appellant's claims, the Board is of the opinion that the appellant's claims of service connection for ptosis, bilateral, with corrective surgery, and service connection for arthritic complaints, are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999). See Gaines v. Brown, 11 Vet. App. 353, 357 (1998) (citing Cohen v. Brown, 10 Vet. App. 128, 136-37 (1997); and Caluza v. Brown, 7 Vet. App. 498, 506 (1995). See also O.G.C. Precedent 67-90. 55 Fed Reg. 43253 (1990); O.G.C. Precedent 82-90, 55 Fed. Reg. 45711 (1990). B. Entitlement to service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye. I. Factual Background The appellant's service medical records are negative for any complaints or findings of iritis, rheumatoid arthritis, and/or HLA-B27 positive uveitis in the right eye. The appellant's separation examination, dated in August 1983, shows that at that time, in response to the question as to whether the appellant had ever had or if he currently had, swollen or painful joints, eye trouble, arthritis, rheumatism, or bursitis, the appellant responded "yes." At that time, the examining physician noted that the appellant had undergone surgery in order to have his eye lids raised. The examiner further indicated that the appellant had male Turner's syndrome, which included ptosis. The appellant's eyes were clinically evaluated as abnormal. The appellant's distant vision was 20/200, bilaterally, and corrected to 20/30, bilaterally. The examining physician noted that the appellant's eyesight was worse. In November 1995, the RO received additional service medical records for the appellant. The records are negative for any complaints or findings of iritis, rheumatoid arthritis, and/or HLA-B27 positive uveitis in the right eye. Private medical records from R.C.H., M.D., from July 1995 to September 1996, show that in August 1995, the appellant was treated with acute iritis in the right eye which was "better." The records reflect that in September 1996, the appellant was treated after complaining of horizontal diplopia. At that time, the physical examination showed that the appellant's corneas were clear except for a few fine "KP" in the right eye. There was good lid closure. The impression was of recurrent iritis, secondary to rheumatoid arthritis. In December 1996, the appellant underwent a VA examination. At that time, he stated that in 1963, he had undergone eyelid surgery for ptosis in both eyes. The appellant indicated that his surgery was repeated in 1982 because his ptosis had recurred. The appellant noted that at present, he was being treated for dry eye and had to use artificial tears. He reported that he was extremely far sighted in both eyes, and that he took two percent homatropine in the right eye and one percent "Pred Forte." The examining physician noted that the "Pred Forte" was taken every two hours for acute "HLA- B27 positive uveitis" ankylosis spondylitis (doubt Reiter's disease) (questionable). The appellant indicated that after his service in Vietnam, he developed arthritis. According to the appellant, at present, he had pain in the multiple joints of the arms and legs. The examiner stated that whether the appellant's complaints were related to his current HLA-B27 positive uveitis and arthropathy was not known. The examiner noted that the appellant did not have any diplopia or visual field defects. Upon physical examination, the appellant was 20/40 +2 far corrected in the right eye, and 20/30 -1+1 far corrected in the left eye. At "near," the appellant was "J1" with his glasses. The appellant's right cornea was clear, and there were no keratic precipitates. The anterior chamber was quiet, with no flare, but he had deposits of posterior iris material on his anterior lens capsule. The appellant had synechia at "5:30," which was not broken by dilating eye drops, and the anterior vitreous was quiet. The left eye looked within normal limits and had a normal pupil, with no evidence of any iridocyclitis. The diagnoses included the following: (1) HLA-B27 positive uveitis in the right eye, which was probably ankylosing spondylitis, (2) high hyperopia, and (3) presbyopia. The examiner stated that the appellant's ankylosing spondylitis had recurred twice and appeared to be well-treated, even though he had synechia at "5:30" and did not seem to have any other complications of the uveitis glaucoma cataract vitreal or retinal damage. In the appellant's February 1998 NOD, the appellant stated that originally, he had had flare-ups of his iritis approximately once a year, but that at present, the flare-ups occurred almost monthly. He indicated that at times, he was unable to tell if his eye problem was iritis or a minor eye irritation. However, the appellant reported that whenever he sought treatment for his eye problem, he was always told that he had iritis. The appellant noted that his treatment included eye drops four times a day. He further stated that in 1964, he had to undergo eye lid surgery, and that in 1988, it was discovered that the stitches had broken. According to the appellant, subsequently, he underwent a second eye lid surgery. He reported that in 1994, it was once again determined that the sutures had broken. The appellant stated that because of the two surgeries, scarring tissues had blocked his tear ducts, which had caused other complications such as dry eye. II. Analysis The threshold question to be answered is whether the appellant has presented evidence sufficient to justify a belief by a fair and impartial individual that his claims for service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye, is well-grounded; that is, a claim which is plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Chelte v. Brown, 10 Vet. App. 268, 270 (1997) (citing Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990)). If the claim is not well grounded, the appeal must fail and there is no further duty to assist in developing the facts pertinent to the claim. See Epps v. Gober, 126 F.3d 1464, 1469 (Fed.Cir. 1997). Generally, a well-grounded claim for service connection requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. Caluza, 7 Vet. App. at 489, 504, 506 (1995); see also Epps v. Gober, 126 F.3d at 1468 (expressly adopting definition of well-grounded claim set forth in Caluza, supra). For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim must be presumed. Robinette v Brown, 8 Vet. App. 69, 75 (1995). Where the determinant 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; if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide 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). To summarize, the appellant contends, in essence, that during service, he developed iritis and arthritic problems. He states that at present, he has monthly flare-ups of his iritis and arthritic problems. In this regard, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. Layno v. Brown, 6 Vet. App. 465 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). However, when the determinative issues involves a question of medical causation, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The evidence does not show that the appellant possesses medical expertise, nor is it contended otherwise. Therefore, his opinion that his recurrent iritis is related to service is not competent evidence. As previously stated, the appellant's service medical records are negative for any complaints or findings of iritis, rheumatoid arthritis, and/or HLA-B27 positive uveitis in the right eye. The first medical evidence of iritis is in August 1995, approximately 12 years after the appellant's separation from the military. The private medical records from Dr. R.C.H. show that in August 1995, the appellant was treated with acute iritis in the right eye which was "better." The records further reflect that in September 1996, the appellant was treated after complaining of horizontal diplopia. At that time, the physical examination showed that the appellant's corneas were clear except for a few fine "KP" in the right eye. There was good lid closure. The impression was of recurrent iritis, secondary to rheumatoid arthritis. In addition, in the appellant's December 1996 VA examination, the appellant was diagnosed with the following: (1) HLA-B27 positive uveitis in the right eye, which was probably ankylosing spondylitis, (2) high hyperopia, and (3) presbyopia. In light of the above, although the evidence of record shows that the appellant currently has recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye, the records do not show a nexus between any current iritis or HLA-B27 positive uveitis in the right eye, and any disease or injury in service. As previously stated, there must be medical evidence showing a nexus between an in- service injury or disease and the current disability for a well-grounded claim. Therefore, as there is no competent medical evidence which shows that the appellant's current recurrent iritis, HLA-B27 positive uveitis in the right eye, is related to service, the appellant's claim of service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B27 positive uveitis in the right eye, must be denied. The Board recognizes that this claim is being disposed of in a manner that differs from that used by the RO. The RO denied the appellant's claim on the merits, while the Board has concluded that the claim is not well grounded. However, the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well grounded analysis." See Meyer v. Brown, 9 Vet. App. 425, 432 (1996). Likewise, the Board finds that the RO has advised the appellant of the evidence necessary to establish a well grounded claim. Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). ORDER The claim of entitlement to service connection for ptosis, bilateral, with corrective surgery, is well grounded. The claim of entitlement to service connection for arthritic problems is well grounded. Entitlement to service connection for recurrent iritis, secondary to rheumatoid arthritis, HLA-B-27 positive uveitis in the right eye is denied. REMAND In regards to the appellant's claims for service connection for ptosis and service connection for arthritic complaints, as the appellant has submitted well-grounded claims, the VA has a duty to assist him in developing the facts pertinent to his claims. 38 U.S.C.A. § 5107(a). The Board notes that in light of the aforementioned evidence and the appellant's diagnoses of orthopedic problems, secondary to Noonan's syndrome, and a history of operation for ptosis, secondary to Noonan's syndrome, it is the Board's conclusion that additional actions and development must be undertaken by the RO prior to further appellate review. The statutory duty to assist the appellant in the development of evidence pertinent to his claims includes a contemporaneous and thorough examination when appropriate. Littke v. Derwinski, 1 Vet. App. 90 (1990). Therefore, the Board is of the opinion that another VA examination, as specified in greater detail below, should be performed. Accordingly, this case is REMANDED for the following actions: 1. The RO should schedule the appellant for a comprehensive VA examination by an appropriate specialist to determine the nature and extent of his Noonan's syndrome. The examiner is requested to review the claims file, including the appellant's service medical records. All necessary special studies or tests are to be accomplished, including x-rays. In reviewing the appellant's case, the examiner is further requested to offer an opinion as to whether the appellant's diagnosed ptosis and arthritic problems, to include arthritis of the cervical, thoracic, and lumbar sections of the spine, are features of his Noonan's syndrome. If so, did the appellant's Noonan's syndrome worsen during service? If the condition worsened during service, was it due to the natural progression of the condition or could it be contributed to the appellant's period of service? In the alternative, the examiner is also requested to offer an opinion as to whether any current disability manifested by degenerative joint disease, to specifically include the cervical, thoracic, and lumbar sections of the spine, had its onset during the appellant's period of active duty service, taking into consideration the appellant's service medical records and the findings noted therein. 2. After the development requested above has been completed to the extent possible, the RO should again review the record. If the examination report is not responsive to the Board's questions, corrective action should be taken. Thereafter, the RO should readjudicate the issues of entitlement to service connection for ptosis, bilateral, with corrective surgery and entitlement to service connection for arthritic problems. If the benefits sought on appeal remain denied, the appellant and his representative should be furnished a supplemental statement of the case and an opportunity to respond. The case should then be returned to the Board for further appellate consideration. The Board intimates no opinion as to the ultimate outcome of the case. The appellant need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. DEBORAH W. SINGLETON Member, Board of Veterans' Appeals