Citation Nr: 0004884 Decision Date: 02/25/00 Archive Date: 03/07/00 DOCKET NO. 95-08 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to a disability rating in excess of 10 percent for exotropia with convergence insufficiency and diplopia. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Kitlas, Associate Counsel INTRODUCTION The veteran served on active duty from March 1969 to September 1972. Service connection was granted for the veteran's exotropia with convergence insufficiency and diplopia by a January 1990 rating decision. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 1994 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied a rating in excess of 10 percent for exotropia with convergence insufficiency and diplopia, among other things. The veteran provided testimony at a personal hearing before the undersigned Board Member in November 1996, a transcript of which is of record. This case was previously before the Board in February 1997, at which time it was remanded for additional development. It has now been returned to the Board for further appellate consideration. As a preliminary matter, the Board finds that the RO has substantially complied with the directives of the prior remand in that additional medical records were obtained, and several VA examinations were accorded to the veteran to determine the current severity of his service- connected disability. Accordingly, a new remand is not required in order to comply with the holding of Stegall v West, 11 Vet. App. 268 (1998). As an additional matter, it is noted that when this case was previously before the Board it included the issue of entitlement to service connection for headaches, including as secondary to exotropia with convergence insufficiency and diplopia. The RO subsequently granted service connection for the veteran's headaches in September 1998. In view of the foregoing, this issue has been resolved and is not on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997), and Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). FINDINGS OF FACT 1. None of the veteran's visual examinations on file show his corrected visual acuity to be 20/40 in one eye with vision in the other eye either 20/50, 20/70, or 20/100. 2. The medical evidence shows that the veteran's diplopia is correctable. 3. The medical evidence on file clearly shows that the veteran has severe nearpoint conversion insufficiency, and that the veteran fatigues extremely quickly. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for exotropia with convergence insufficiency and diplopia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.75, 4.77, 4.84a, Diagnostic Codes 6078 and 6090 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background. Service connection was granted for the veteran's exotropia with convergence insufficiency and diplopia by a January 1990 rating decision. At that time it was noted that the service medical records from June 1970 showed the veteran to have had a three millimeter bilateral medial rectus resection. Follow-up visual acuity three weeks status post surgery showed his vision to be 20/20 right eye, and 20/40 left eye. It was further noted that Medical Evaluation Board findings from July and August 1972 included diagnoses of exotropia at near convergents insufficiency with diplopia. Further, the August 1972 Medical Evaluation Board report determined that his visual acuity was correctable to 20/20 bilaterally. After summarizing the results of a recent VA examination, a 10 percent disability rating was assigned, effective March 24, 1988. The veteran's claim for an increased rating was received by the RO in September 1993. VA medical records were subsequently obtained that were dated in that same month. These records noted that the veteran complained of headaches, as well as long standing lateral diplopia. The veteran also reported that he had never worn glasses. Bifocal eyeglasses were prescribed, and corrected vision was noted to be 20/25 and 20/30. Diagnostic impression was intermittent exotropia with convergence insufficiency and refractive error with presbyopia. A January 1994 VA examination for miscellaneous neurological disorders noted that the veteran complained of double vision with headaches, bitemporal with neck stiffness without any vomiting, and relieved with sleep. Objective findings included the determination that the pupils were equal, round, regular, react to light and accommodation. Extraocular muscles were noted to be intact. Further, the veteran's field of vision was found to be within normal limits. There was no evidence of nystagmus. Diagnoses included diplopia. In a June 1994 rating decision, the RO denied a disability rating in excess of 10 percent for the veteran's exotropia with convergence insufficiency and diplopia. The veteran appealed this decision to the Board. Thereafter, the veteran underwent a VA visual examination in September 1994. Objective findings revealed his best corrected mission for the right eye was 20/20 and the left eye was 20/50 at distance and near. Further, it was noted that the left eye was amblyopic. Pupils were found to be 4.5 mm with a 3+ direct and consensual response for both eyes, and "NO MG" both eyes. Extraocular muscles were unrestricted in each eye, and no diplopia was reported in distances greater than 12 inches from the face. However, it was noted that the veteran reported horizontal diplopia in viewing distances closer than 12 inches because of lack of convergence in distances closer than 12 inches. Visual field was found to be normal in each eye. Additionally, it was noted that slit lamp exam revealed unremarkable anterior segment and posterior segment findings with a minimum "c/d" in both eyes, and deep orange, distinct disc margins for both eyes. Macular reflex was seen in both eyes. Diagnoses included left eye congenital amblyopia with vision correctable to 20/50. It was stated that no pathology was present in the left eye and with the history of strabismus surgery, it was obvious that the veteran had congenital strabismus with left eye amblyopia. Additionally, it was emphasized that the veteran had diplopia at viewing distances closer than 12 inches because of lack of convergence. It was also stated that normal near viewing distances were 16 inches and greater. Thus, the veteran had to hold reading material at distances greater than 12 inches. New bifocal specs were recommended as a result of this examination. The veteran subsequently underwent a new VA examination for miscellaneous neurological disorders in November 1994. At this examination, it was noted that the veteran's main complaints were headaches and soreness of his eyes. On examination, it was noted that the veteran did have an abnormality of convergence. Specifically, his left eye did not converge properly medially, although it did move in that direction unrelated to convergence. The examiner opined that this did not appear to be a neuromuscular problem of such. It was also noted that neurological and opthalmological examination revealed fundi that were clear. Further, extraocular movements were essentially normal, except for the defective convergence. Additionally, it was noted that the veteran had a squint in his left eye. Cranial nerves were otherwise intact. Similarly, the sensory system, motor system, and cerebellar system were also found to be intact. Overall diagnoses included convergence disorder, left eye. The veteran was also diagnosed with a refraction abnormality. His vision was found to be marginal; he could see, but not well without his glasses. At his November 1996 personal hearing, the veteran testified, in part, that his eye problems had gotten worse. He testified that he experienced eye problems at work, in that his job involved a lot of reading, among other things, and it took him longer to read and learn because of his eye problems. Also, he indicated that he had to give up sports, hunting, and other activities as a result of his double vision. He testified that sunlight really made his eyes tired. Further, the veteran indicated that his eye problems got progressively worse during the day. He indicated that the severity of these problems depended on what he did the night before, and how much reading, etc., that he has to do during the day. Additionally, he testified that he had tearing of the eyes, and that his eyes would feel sore. However, he was not aware of any infections. The veteran further testified that he had not lost any time from work because of his eye problems. He testified that he used no medications except for aspirin and things of that nature. It is noted that he also indicated that he used eye drops. He also testified that VA had given him three separate sets of eyeglasses, but that they were of no help. Various VA medical treatment records are on file that cover the period from September 1993 to February 1997. These records show treatment for visual problems. Visual acuity findings include 20/25 for both eyes; and 20/25 for the right eye, and 20/30 for the left. On a February 1998 VA visual examination, it was stated that the veteran had profound convergence insufficiency of greater than 10 prism diopters at near, with profound diplopia that was easily documented at near which triggered significant eye strain and profound headache. It was further stated that the visual defect at near was quite severe, and easily reproducible. Also, the diplopia at near was present at 13 inches both to the right, left, and center of the veteran's visual field. It was noted that his central visual acuity at near with bifocals was normal, although it was double. The examiner specifically noted that a review of the veteran's claims file was made. Also on file are private medical statements from a Dr. Farris, dated in June 1997, August 1997, and June 1998. In the June 1997 statement, it was noted that neuro- opthalmologic examination revealed the veteran's best corrected visual acuity was 20/20+1 in the right eye, and 20/20-2 in the left eye. Also, muscle balance and motility examination demonstrated 5 prism diopters of exophoria in primary gaze at distance, increasing to 16 prism diopters of exotropia at near. The rest of the neuro-ophthalmologic examination was found to be entirely within normal limits with the exception of a dry eye syndrome. In the August 1997 statement it was noted, among other things, that the veteran had a long-standing convergence insufficiency. In the June 1998 statement, Dr. Farris reiterated the findings of the June 1997 neuro-opthalmologic examination. Also on file is a private medical statement from a Dr. Brian, who noted that the veteran underwent an eye examination in July 1998, which revealed a very narrow near point of convergence of greater than 20 inches, as well as a high degree of exophoria up close. Dr. Brian stated that these objective findings were consistent with the veteran's subjective complaints of double vision up close. There is also a November 1998 private medical statement from a Dr. Romano, who noted that a recent eye examination showed the veteran's visual acuities, without correction, to be 20/40 for the right eye, and 20/100 for the left eye. Visual acuities, with correction, were 20/20-1 for the right eye, and 20/25 for the left eye. Dr. Romano's impressions were that the veteran had severe nearpoint conversion insufficiency. Additionally, it was noted that the veteran fatigued extremely quickly at nearpoint and had no stereopsis at near. A new VA visual examination was accorded to the veteran in January 1999. At that time, it was noted that the veteran's chief complaint was diplopia within 12 inches of eyes, and that this distance could increase depending on how tired or stressed he was, or how he was feeling. Objective evaluations showed that the veteran's visual acuity, with correction, was 20/20 for the right eye, and 20/40+ for the left eye. It was noted that a previous report documented probable congenital strabismus with amblyopia of the left eye. Pupils were found to be 5 mm for both eyes, with no afferent pupillary defect (APD). Extraocular muscles were found to be unrestricted for both eyes. However, it was noted that the veteran was unable to converge/fuse within 16 inches from his face without the aid of prisms. Confrontation fields were found to be full for both the right and left eye. It was noted that phoropter testing revealed 18 prism diopters "exo" at or near with inability to see singly unless 3 p.d. basie-in prism was added to each eye. Also, Goldmann testing revealed diplopia in all gazes unless prism was incorporated, which eliminated the diplopia. It was noted that a dilated fundus exam was not done as the veteran reported he had just had this exam done two months earlier. Overall assessment was diplopia within 16 inches, but correctable with prism. It was noted that new eyeglasses were to be ordered for the veteran for near work that incorporated this prism. The veteran also underwent VA Goldmann bowl testing for diplopia in April 1999. At this examination, the veteran gave a history of longstanding near point problems with intermittent diplopia, eye strain, and blurred vision during near vision tasks since eye muscle surgery by the military in the 1970s. The veteran reported that this surgery gave him the problems and that he just wanted to be compensated for it fairly. He also stated that the near point problems worsened depending on the task, stress, or how he was feeling especially now that he's getting older. On objective examination, the Goldmann bowl testing distance was 12 inches outside the veteran's near point of convergence, so diplopia was seen in all gazes with lens correction but no prisms. The examiner noted that prism was gradually incorporated in a trial frame until the veteran saw singly within the Goldmann bowl. Gaze testing revealed no diplopia until 10 degrees in all directions. However, it was determined that this was caused by the trial frame and trial lens rims, which restricted gazes to 10 degrees in all directions. The examiner stated that there was nothing he could do about this restriction because this was the only way to mount the prism. Additionally, the examiner stated that he wanted to clarify two important points of the veteran's case. First, the contention that the veteran's double vision (diplopia) was caused by the in-service eye muscle surgery. The examiner stated that a review of the veteran's claims file clearly documented that the diplopia, exotropia, and headaches were present before the surgery. (Emphasis in original). Second, the examiner stated that the amount of exotropia at near was actually somewhat improved since the surgery. It was noted that the claims file documented 20 prism diopters of exotropia before the surgery, and that examinations after the surgery had revealed less exotropia. Thus, it did not appear that the exotropia was made worse after the surgery. Further, the examiner emphasized that the veteran had convergence insufficiency at near with associated near exotropia and diplopia, which testing revealed to be correctable with prism. Since there was no history of supranuclear condition caused by cerebrovascular accident, head trauma, inflammatory or post viral illness, it was the examiner's opinion that this was a condition that the veteran always had, but that it became more aggravated as an adult by intense near vision work and now, more recently, by the onset of presbyopia. In a September 1999 Supplemental Statement of the Case, the RO confirmed and continued the 10 percent disability rating for the veteran's exotropia with convergence insufficiency and diplopia. The RO found that the medical evidence showed the veteran's visual acuity and diplopia were considered zero percent disabling, but that the 10 percent rating was continued due to the fact that the veteran did have severe nearpoint conversion insufficiency and fatigues extremely quickly. Further, the RO stated that a higher evaluation required greater impairment of vision or diplopia which was not correctable. Legal Criteria. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of use- fulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In evaluating the veteran's exotropia with convergence insufficiency and diplopia, the RO has considered the criteria found at 38 C.F.R. § 4.84, Diagnostic Codes 6078 and 6090. Under the provisions of 38 C.F.R. § 4.75, the best distant vision obtainable after best correction by glasses will be the basis of rating for impairment of visual acuity. Under the provisions of 38 C.F.R. § 4.84a, Diagnostic Code 6078, a 10 percent rating is warranted when vision in one eye is 20/40 and vision in the other eye is either 20/50, 20/70, or 20/100; or if vision in both eyes is 20/50. A 20 percent rating is warranted if vision in one eye is 20/40 and vision in the other is 20/200; or if vision in one eye is 20/50 and vision in the other is 20/70 or 20/100. 38 C.F.R. § 4.84a. Pursuant to Diagnostic Code 6092, diplopia, or double vision, due to impaired muscle function is rated under the provisions of Diagnostic Code 6090 for diplopia. Under Diagnostic Code 6090, findings relating to diplopia are equated to loss of visual acuity. Thus, specific findings of diplopia are converted into terms that lend themselves to the mechanical application of 38 C.F.R. § 4.84a, Table V, which sets forth the "Ratings for Central Visual Acuity Impairment." The specific equivalent visual acuity is as follows: (a) Central 20° 5/200 (b) 21° to 30°: (1) Down 15/200 (2) Lateral 20/100 (3) Up 20/70 (c) 31° to 40°: (1) Down 20/200 (2) Lateral 20/70 (3) Up 20/40 However, it is important to note that the measurement of eye muscle function will be undertaken only when the history and findings reflect disease or injury of the extrinsic muscles of the eye, or of the motor nerves supplying these muscles. The measurement will be performed using a Goldmann Perimeter Chart which identifies four major quadrants, (upward, downward, and two lateral) plus a central field (20 ° or less). Muscle function is considered normal (20/40) when diplopia does not exist within 40° in the lateral or downward quadrants, or within 30° in the upward quadrant. Impairment of muscle function is to be supported in each instance by record of actual appropriate pathology. Diplopia which is only occasional or correctable is not considered a disability. 38 C.F.R. § 4.77. The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). With regard to the veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Analysis. In general, a veteran's claim of increasing severity of a service-connected disability establishes a well-grounded claim for an increased evaluation. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Therefore, the Board finds that the veteran's claim for an increased evaluation for his exotropia with convergence insufficiency and diplopia is well-grounded. Because the claim is well grounded, VA has a duty to assist the veteran in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a). Here, VA has accorded the veteran several examinations in relation to this claim, obtained medical records pertaining to the treatment he has received for his visual problems, and provided him with the opportunity to present testimony regarding his claim at a personal hearing. There does not appear to be any pertinent medical evidence that is not of record or requested by the RO. Thus, the Board finds that VA has fulfilled its duty to assist the veteran in developing the facts pertinent to this claim. In the instant case, the Board concurs with the RO's findings that the medical evidence does not demonstrate that the veteran's visual acuity or his diplopia warrants a compensable disability rating under the applicable Diagnostic Codes; he does not meet the specified criteria for a 10 percent rating under either Diagnostic Code 6078 or 6090. None of the veteran's visual examinations on file show his corrected visual acuity to be 20/40 in one eye with vision in the other eye either 20/50, 20/70, or 20/100. In fact, the January 1999 VA visual examination - which is the most recent visual examination on file - found the veteran's vision to be 20/20 for the right eye, and 20/40+ for the left eye. Thus, the veteran is not entitled to a compensable rating under 38 C.F.R. § 4.84a, Diagnostic Code 6078. As mentioned above, it was determined at the January 1999 VA visual examination, and the April 1999 VA Goldmann bowl testing, that the veteran's diplopia is correctable. Pursuant to 38 C.F.R. § 4.77 diplopia which is correctable is not a disability. Therefore, the veteran is not entitled to a compensable rating under 38 C.F.R. § 4.84a, Diagnostic Code 6090. Nevertheless, the medical evidence on file clearly shows that the veteran has severe nearpoint conversion insufficiency, and that the veteran fatigues extremely quickly. The evidence in support of this finding includes the November 1998 statement from Dr. Romano, and the veteran's hearing testimony that his visual problems became progressively worse during the day. This evidence supports the compensable rating of 10 percent assigned by the RO for his exotropia with convergence insufficiency and diplopia. See 38 C.F.R. §§ 3.102, 4.3, 4.7. The Board notes, however, that none of the medical evidence on file contain objective findings that meet or nearly approximate the criteria for the next higher rating of 20 percent under either Diagnostic Code 6078 or 6090. Accordingly, the Board finds that the preponderance of the evidence is against the veteran's claim for a disability rating in excess of 10 percent, and it must be denied. ORDER Entitlement to a disability rating in excess of 10 percent for exotropia with convergence insufficiency and diplopia is denied. WAYNE M. BRAEUER Member, Board of Veterans' Appeals