Entitlement to service connection for bilateral dry eye syndrome is granted.

Citation Nr: 26001433 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 13-16 829 DATE: January 30, 2026 ORDER Entitlement to service connection for bilateral dry eye syndrome is granted. Entitlement to service connection for a heart disability, to include hypertension, hypertensive heart disease, bradycardia, and valvular heart disease, is denied. FINDINGS OF FACT 1. The Veteran's only current eye disability is bilateral dry eye syndrome; the Veteran's bilateral dry eye syndrome is directly related to in-service eye surgery. 2. The evidence of record persuasively weighs against finding that the Veteran's heart disability, to include hypertension, hypertensive heart disease, bradycardia, and valvular heart disease, began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral dry eye syndrome have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a heart disability, to include hypertension, hypertensive heart disease, bradycardia, and valvular heart disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1988 to August 1996. The Veteran testified at a December 2019 Board Hearing held before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In an April 2020 Board Decision, the above-referenced claims were remanded to the RO for further evidentiary development and readjudication. The RO has substantially complied with the Board's remand instructions with respect to the above-listed claims, so the Board may proceed to their merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). In addition to the above-referenced claims, the April 2020 Board decision also remanded claims of entitlement to service connection for a gynecological condition to include urological symptoms, for asthma, and for an acquired psychiatric disorder to include PTSD with depression. The AOJ granted entitlement to service connection for stage II uteropelvic organ prolapse and for mixed urinary incontinence as related to the uteropelvic organ prolapse, in a June 2024 rating decision. This represented a full grant of benefits as these disabilities represent all of the diagnosed disabilities encompassed by the Veteran's claim. See, e.g., March 2022 VA Examination (diagnosing uteropelvic organ prolapse). The AOJ also granted entitlement to service connection for PTSD with depressive disorder in the June 2024 rating decision, which was a full grant of benefits sought with respect to the psychiatric disorder claim. Finally, the AOJ granted entitlement to service connection for asthma in a June 2025 rating decision, which also represented a full grant of benefits. Notably, the asthma claim was granted pursuant to the PACT Act which became law in the course of this legacy appeal. The Board has considered whether there remains a portion of that service connection claim on appeal, but determines that it is not because the Veteran has the full right to appeal the effective date, which is a downstream element separate from the original appeal regarding service connection. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed.Cir. 1997) (clarifying that an appeal regarding downstream elements, i.e. the disability rating and effective date, is separate from any prior appeal regarding entitlement to service connection). Specifically, this case does not fall within the special category outlined in Concepcion-Maldonado v. Collins, 38 Vet. App. 294 (June 23, 2025), which requires the Board to retain jurisdiction of and decide a portion of a service connection claim in certain circumstances. Concepcion-Maldonado involved a Board dismissal of a legacy appeal of a claim of entitlement to service connection for a neck disability. During the pendency of that legacy appeal (arising from a July 2016 claim), the AOJ granted entitlement to service connection for the neck disability and assigned an effective date in accordance with the date of the January 2023 supplemental claim in that AMA appeal stream. The Court held that the Board erred in dismissing the legacy appeal as moot, because the earliest possible effective date in the legacy appeal was earlier than the earliest possible effective date in the AMA appeal stream which granted the neck disability claim. Id. at 297 ("We hold that a VA grant in a modernized claim can't moot a legacy claim for the same benefit when an earlier effective date is possible through the legacy appeal."); see also Johnson v. Collins, 38 Vet. App. 151, 164 (March 26, 2025) (holding that the Board erred in dismissing as moot a legacy appeal where the AOJ had granted service connection "in a separate and distinct claim stream and based on the liberalizing PACT Act"). Here, there are not separate and distinct claim streams, but a single legacy appeal remanded by the Board in 2020, readjudicated by the AOJ in a June 2024 rating decision (gynecological and psychological disorders), in a June 2025 supplemental statement of the case (heart and eye conditions), and a June 2025 rating decision (asthma), all of which were explicitly adjudicated as part of this legacy appeal stream. This is in contrast to Concepcion-Maldonado and Johnson which each involved a legacy appeal and the impact of a later AOJ decision regarding an AMA claim in a separate appeal stream. The Concepcion-Maldonado and Johnson decisions involved a conflict between the relief available in, on the one hand, a legacy appeal stream before the Board and, on the other hand, a later AMA appeal stream in which a "separate and distinct claim" was decided by the AOJ. There is no such conflict here. This situation involves a single claim in a legacy appeal in which the AOJ granted service connection after remand from the Board. The question of whether the Veteran would be able to seek the earliest possible effective date on appeal and consequent mootness concerns addressed in Concepcion-Maldonado are not present here, so the ordinary rules apply. The effective date to be assigned is a downstream element subject to separate appeal, pursuant to Grantham, supra. The single claim of entitlement to service connection for asthma in this single legacy appeal stream was granted by the AOJ in a June 2025 rating decision, so the full benefits sought in this appeal with respect to service connection for asthma have been granted. The Veteran has until June 9, 2026, if she wishes to pursue an earlier effective date. For these reasons, there is no remaining appeal before the Board regarding a gynecological condition (to include urinary symptoms), asthma, or an acquired psychiatric disorder. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for bilateral dry eye syndrome The Veteran contends that she has an eye disability that is related to her active service. See November 2009 VA Form 21-4138 (seeking service connection for "bilateral eye condition"); July 2020 Notice of Disagreement (disagreeing with denial of service connection for an eye condition); November 2019 VA Form 646 (arguing that the Veteran is entitled to service connection for multiple disabilities, including bilateral eye disability, "based on the belief that [the] disabilities began during her time in the Army"); December 2019 Board Hearing Tr. at 29-32 (discussing the Veteran's contentions regarding in-service events and noting she was going to meet with a specialist to "[p]erhaps get some diagnoses"). The Board concludes that the Veteran has a current disability that is related to the Veteran's active service including eye surgery during her active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA treatment records show the Veteran has a current diagnosis of dry eye syndrome which was also confirmed at the July 2024 VA examination. The examiner found no other current eye disabilities. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence in favor of the claim includes a favorable July 2024 VA examiner's opinion in which the VA examiner noted the current bilateral dry eye syndrome was a sequalae of the in-service eye surgery. There are no unfavorable opinions of record. The Board briefly notes that the AOJ denied the claim on the basis that the in-service surgery was for a congenital condition and that, pursuant to 38 C.F.R. § 3.306(b)(1), "service connection cannot be established for the usual effects of medical or surgical treatment in service to correct" a congenital condition. While that statement of the law is true, there are multiple problems in applying it to the facts of this case. First, the entrance examination did not note any eye condition or abnormality of the eye upon the Veteran's entry into service. Given that is the case, VA would first have to establish by clear and convincing evidence that the Veteran had a pre-existing eye condition. That standard cannot be met on the current record as the in-service diagnosis was a "provisional diagnosis" of conjunctival melanoma. See also May 1993 STR ("Conj. - melanosis... noticed 4 yrs ago. gotten larger..."); October 1993 STR ("Discharge Diagnosis: Conjunctival [illegible]"). While there are indications in the record that it may be congenital, see May 1992 STR (diagnosing "congenital hyperpigmentation"), this evidence is insufficient to establish that the Veteran had a pre-existing or congenital eye condition, particularly with notations that the first appearance was during service and without any definitive opinion regarding whether the condition was, in fact, congenital. Second, the condition definitely worsened during service, so VA would bear the burden of showing by clear and unmistakable evidence that the pre-existing or congenital condition was not aggravated by service. There are no opinions to that effect here and the fact that the purportedly congenital condition was first noticed during service and then worsened during service weighs heavily against any such conclusion absent a definitive opinion to the contrary with a convincing rationale. Third, for 38 C.F.R. § 3.306(b)(1) to apply, the record would have to establish not only that dry eye syndrome resulted from surgery, but that dry eye syndrome would be a "usual effect" of surgery for the Veteran's condition. The only evidence on this record is that the Veteran did develop dry eye syndrome as a result of surgery, not that dry eye syndrome is a "usual effect" of that surgery. Consequently, the record is inadequate to deny the claim on pursuant to 38 C.F.R. § 3.306(b)(1). The Board finds that additional development is not warranted as the VA examiner gave no indication that any of these medical questions would be answered adversely to the Veteran and remand purely for adverse development is not appropriate. The record contains a favorable opinion and, therefore, the current record is sufficient to grant the claim. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current dry eye syndrome is related to her active service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for dry eye syndrome is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a heart disability, to include hypertension, hypertensive heart disease, bradycardia, and valvular heart disease The Veteran contends that she has a heart disability, to include hypertension, though she did not know the specific diagnosis of her current condition. See November 2009 VA Form 21-4138 (seeking service connection for "heart condition"); July 2020 Notice of Disagreement (disagreeing with denial of service connection for a heart condition); November 2019 VA Form 646 (arguing that the Veteran is entitled to service connection for multiple disabilities, including a heart disability, "based on the belief that [the] disabilities began during her time in the Army"); December 2019 Board Hearing Tr. at 14 ("Q. You don't know specifically what type of heart condition you have? A. No sir."). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of hypertension, hypertensive heart disease, bradycardia, and valvular heart disease, and evidence shows that the Veteran had in-service chest pains and occasional elevated blood pressure readings, the evidence of record persuasively weighs against finding that the Veteran's diagnoses of hypertension, hypertensive heart disease, bradycardia, and valvular heart disease began during service or are otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with hypertension until 1996 (as reported by the Veteran, but not noted in treatment records for many years after) years after service and was not diagnosed with hypertensive heart disease until 2024, with bradycardia until March 2022, and with valvular heart disease until 2024, all decades after separation from service. See July 2024 VA Examination (Hypertension); July 2024 VA Examination (Heart); March 2022 VA Examination (Heart); March 2024 VA Examination (Hypertension); see also August 2016 VA Surgery Note ("no history of a heart condition"). While the Veteran is competent to report having experienced symptoms of chest pain and elevated heart rate intermittently since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of any of her currently diagnosed heart disabilities. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, interpretation of complicated diagnostic medical testing, and the diagnostic criteria for various possible causes of the subjectively observed symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the July 2024 VA examiner and March 2022 VA examiner both opined that the Veteran's hypertension is not at least as likely as not related to an in-service injury, event, or disease, including chest pain and elevated blood pressure readings during service. The rationale of the March 2022 VA examiner was that the Veteran only had one instance of chest pain and no further complaints, so the hypertension was unlikely related to that episode. The examiner did not address the elevated blood pressure readings in service, so only has probative value with respect to whether the hypertension is related to in-service chest pain. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The July 2024 VA examiner (in an August 2024 opinion ) addressed whether the Veteran's later diagnosed hypertension was related to elevated blood pressure readings during service. The examiner opined that blood pressure readings fluctuate and can be elevated during acute illnesses and the in-service records did not show a consistent number of abnormally elevated blood pressure readings, so it was unlikely that the current hypertension is related to the elevated blood pressure readings during service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A May 2025 VA examiner's opinion was also that the Veteran's hypertension was less likely than not related to elevated blood pressure readings during service. The rationale was the same as that of the July 2024 VA examiner. The May 2025 VA examiner also opined that the Veteran's hypertension was less likely than not due to her participation in toxic risk exposure activities (TERA) during service, to include the synergistic, combined effect of all of her TERA. The examiner explained that the Veteran had multiple known risk factors, including diabetes, obesity, and family history, which were a more likely cause of the Veteran's hypertension than any toxic exposures. The examiner included extensive citations to medical literature. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. With respect to the other heart conditions, there are also opinions against the claim. The March 2022 VA examiner opined that the Veteran's heart condition was unlikely related to the complaint of chest pain during service. The examiner noted that there was only a single documented complaint of chest pain and no further complaints thereafter and no diagnosis of a heart condition for many years after. Therefore, the condition is unlikely related to service. The opinion contains an adequate rationale with respect to the in-service events addressed by the examiner (chest pain), so has some probative value against the claim with respect to that theory. The opinion otherwise does not have probative value given additional theories subsequently put forward in the record. The August 2024 VA examiner's opinion was that the Veteran's heart condition was less likely than not due to her participation in TERA during service, to include the synergistic, combined effect of all of her TERA. The examiner noted that there are multiple potential causes of the Veteran's diagnosed heart conditions and the Veteran's heart disability was more likely related to intrinsic and extrinsic etiologies other than participation in TERA. The examiner noted that the Veteran reported a long history of hypertension and the Veteran's hypertensive heart disease was more likely due to her longstanding hypertension. The opinion contains an adequate rationale and is entitled to probative value against the claim. Nieves-Rodriguez, 22 Vet. App. at 304. The record does not contain any favorable opinions. Because there are probative opinions against the Veteran's claim and no competent opinions linking the Veteran's heart disabilities, to include hypertension, to her active service, the evidence is persuasively against the Veteran's claim. The evidence is not in approximate balance, but is persuasively against the claim, therefore there is not reasonable doubt to be resolved in favor of the Veteran. 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021). Entitlement to service connection for a heart disability, to include hypertension, hypertensive heart disease, bradycardia, and valvular heart disease, is denied. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hubers, Kerry The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.