BVA9502511 DOCKET NO. 93-08 429 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to a compensable evaluation for the residuals of a right eye injury, presently characterized as residuals of right eye iritis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Johnston, Associate Counsel INTRODUCTION The veteran had active duty from October 1950 to September 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1992 rating decision of the Chicago, Illinois, Department of Veterans Affairs (VA) Regional Office (RO). REMAND The veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (1991), in that it is plausible. The VA therefore has a duty to assist the veteran in the development of facts pertinent to his claim. Additional evidence must be procured before final disposition of the appeal. During service, the veteran had a finger poked in his right eye during a basketball game. He was treated for right eye hemorrhage. An examination after service showed the right eye pupil to be larger than the left and the margins of the right eye were irregular and adherent to the lens capsule. "Fixed" (discs?) and fundus were negative. Right eye visual acuity was 20/20 plus 3 when corrected. While the April 1955 VA examination conducted for the purpose of the veteran's initial claim did not refer to right eye iritis, the RO subsequently granted service connection in its initial rating decision of May 1955 for the residuals of right eye iritis. In March 1992, the veteran requested to have his right eye examined and this was treated as a claim for an increased evaluation. An April 1992 VA examination revealed distance vision in the right eye to be 20/400, uncorrected, and 20/40 minus 2 corrected. Left eye acuity was 20/20 uncorrected. There was no report of diplopia or visual field defect and the extraocular muscles were full and smooth, bilaterally. The right eye pupil had a defect in that it was fixed at 3 millimeters. The right eye lens had four-plus nuclear sclerosis with some posterior subcapsular cataract. Right eye fundus view was unobtainable due to the cataract impeding the view. The diagnoses were cataract of the right eye and borderline intraocular pressure of the right eye. Based upon this examination, the RO denied the veteran's claim for an increased evaluation for the residuals of right eye iritis based upon the fact that there was no indication of loss of visual acuity or field of vision due to iritis and there was no indication of active pathology due to iritis. The statement of the case found that the right eye cataract and borderline intraocular pressure for the right eye were not service connected, but there was no substantive discussion as to whether or not these findings were causally related to the right eye trauma the veteran sustained during service. Additionally, we note that these questions were not answered in the April 1992 VA examination as well. Finally, in his VA Form 9, Appeal to Board of Veterans' Appeals, the veteran reported that, in addition to the April 1992 VA examination, he apparently underwent a fee-basis VA eye examination in July and a VA eye examination December 1992. These examinations are not contained in the claims folder and must be obtained before final appellate review. Because additional evidentiary development is required, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request him to submit any additional evidence he may have which is relevant to his claim for an increased evaluation for the residuals of a right eye injury. He should be requested to identify the names and addresses of any private physicians who have examined or treated his right eye since February 1992 and, with the veteran's assistance and consent, the RO should contact any physician identified and request copies of all available records of the veteran's right eye examination or treatment. All records obtained should be added to the claims folder. 2. The RO should obtain copies of all records of VA treatment or evaluation of the veteran's right eye which are not already on file, to include VA eye examinations conducted in both July and December 1992. Any records obtained should be added to the claims folder. 3. Upon completion of the above development, the veteran should be provided an examination by an ophthalmologist. All indicated special studies should be performed. The claims folder, a copy of this remand and all evidence obtained pursuant to the remand should be made available to the examiner for review prior to the actual examination. In addition to providing a current diagnosis and detailed explanation of all relevant findings regarding the veteran's right eye, the examiner should, after reviewing all evidence of record and conducting the examination, render an opinion as to whether it is more, less or equally probable that any additional findings regarding the veteran's right eye, including a right eye cataract and/or increased intraocular right eye pressure, are causally related to the right eye trauma the veteran sustained during service. After completion of the above development, the RO should again address the issue presented on appeal which appears to be appropriately characterized as the residuals of a right eye injury. The RO should accurately determine whether or not each adverse finding regarding the veteran's right eye should be included as a residual of the veteran's right eye injury during service. The RO should then evaluate the veteran's right eye disorder based upon all adverse findings found to actually be residual to the veteran's right eye injury during service. If any part of the decision remains adverse, the veteran and his representative should be provided with an appropriate supplemental statement of the case and a reasonable opportunity to respond. The case should then be returned to the Board for final appellate review. The veteran need do nothing until further notified. RENÉE M. PELLETIER 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) (1993).