RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01995
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Personnel Clerk, medically separated for “right inferotemporal visual field defect” with a disability rating of 10%.  

CI CONTENTION:  The CI listed the following conditions as part of his contention:  migraines, right knee sprain, hearing loss, lumbar sprain, hypertension, ringing in ears, lost vision in lower right hand quadrant of both eyes, tinnitus in both ears, hypertension, and post-traumatic stress disorder (PTSD).  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040901	VARD - 20061228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Inferotemporal Visual Field Defect	6080	10%	Right Lower Quadrant Visual Field Defect	6080	NSC	20050914	
Thoracic Spine Pain 	Cat III/Not Unfitting	Central Disc Herniations, T6-T12, with Chronic Lumbar Sprain	5243	10%	20050810	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Inferotemporal Visual Field Defect.  According to the service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right inferotemporal visual field defect condition began in February 2003 after being involved in two motor vehicle accidents within two days of each other.  The CI stated “he had hit his head possibly on the headrest of his seat and he remembered seeing stars, but did not think he lost consciousness.”  Of interest the CI had a compound, comminuted, and depressed left frontal skull fracture in August 1986 at age 6 for which surgery to elevate bone fragments was performed.  In July 2001 the CI’s visual acuity was 20/20 and in April 2002 it was again 20/20.  

Magnetic resonance imaging (MRI) on 12 March 2003, ordered for loss of vision after the accidents and pain in the right frontal temporal area of the head, demonstrated unremarkable orbits and mucoperiosteal thickening in the sinuses.  An MRI also on 12 March 2003 of the brain and brainstem showed changes of encephalomalacia (softening or loss of brain tissue) in the left temporal lobe and air-fluid levels in the frontal sinuses.  The radiologist advised to check for signs of cerebrospinal fluid rhinorrhea (drainage of fluid surrounding the brain into the nose) and hemorrhage (bleeding).  A note on 19 March 2003 indicated the CI had seen a civilian optometrist who told him he had a loss of peripheral vision in the right eye.  

At an ophthalmology clinic visit also on 19 March 2003 the CI was diagnosed as having a right inferotemporal quadrantanopia (loss of vision lower outside quadrant) of uncertain etiology.  A follow-up MRI on 21 May 2003 showed a focus of probable encephalomalacia involving cortex and subcortical matter in the left frontal region and evidence of inflammatory changes of the paranasal sinuses with a probable small retention cyst or polyps in the maxillary sinuses.  At a follow-up ophthalmology visit on 5 June 2003 there was no change in the fight inferotemporal quadrantanopia.  A single field analysis visual field test of the right eye confirmed the right lower outer quadrant visual defect on 17 September 2003.  An MRI dated 28 October 2003 of the right optic nerve to the chiasm (where the optic nerves cross at the base of the brain) was unremarkable, and there was an abnormal signal in the gray matter of the brain on the left in the high vertex.  

The MEB NARSUM Ophthalmology addendum to the 24 March 2004 MEB NARSUM, 9 months before separation, noted complaints of a persistent visual field deficit of the right eye to involve the entire inferotemporal (lower outside) quadrant.  The left eye was unaffected by any visual field deficit. Ophthalmologic examination showed the CI’s visual acuity in each eye without correction was 20/20.   There was no afferent pupillary defect (to determine an optic nerve defect) and slit lamp examination was unremarkable.  The dilated fundus examination was also unremarkable and a visual field examination demonstrated a complete inferotemporal quadrantanopia of the right eye, while the left eye was unaffected.  In summary, the CI had a persistent visual field deficit of the right eye and there was no demonstrated pathology of the eye by physical examination or on the MRI.  

During the 27 May 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported loss of right quadrant [vision].  The physical examiner checked normal for ophthalmoscopic and did not report any positive findings for the eye examination.  

At the 14 September 2005 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported a decline in his peripheral vision in both eyes after head trauma in a motor vehicle accident in February 2003.  Ophthalmologic examination revealed visual acuity without correction was 20/20 in both eyes for both distance and near vision.  His color vision was normal and steroacuity was normal at 40 seconds of arc.  Pupils were equal and reactive to light and accommodation.  There was no evidence of an afferent papillary defect.  Extraocular motility was full and there was no evidence of strabismus (cross eyes).  Visual fields by confrontation were performed and there appeared to be a depression in the inferotemporal quadrant in the right eye and inferonasal quadrant in the left eye indicating a quadrantanopia defect.  The VA determined the right lower quadrant condition was not service connected.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right inferotemporal visual field defect condition 10%, coded 6080 (visual field defects loss of temporal half of visual field unilateral).  The VA determined the right lower quadrant condition was not service connected, coded 6080, citing “the medical evidence of record does not specifically show that your right lower quadrant visual field defect is related to your in service motor vehicle accidents, as opposed to your childhood skull fracture” and your “in service medical providers specified that the cause an origin of the visual field deficit is unclear.”  

Panel members discussed whether there was any VASRD code that may could provide a higher rating and determined that there was none since the CI had normal visual acuity on several eye examinations.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right inferotemporal visual field defect condition.  

Contended Condition:  Thoracic Spine Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was the basis for the CI to be placed on limited duty for a period of 8 month beginning 2 October 2003 and the Non-Medical Assessment indicated the CI performed “his duties in an outstanding manner, making a positive contribution; however, being non-worldwide assignable due to his medical condition is detrimental to his future in the Navy.”

The 23 April 2004 MEB NARSUM examination, 8 months prior to separation, noted complaints of back pain.  The CI was involved in the first of two motor vehicle accidents on 7 February 2003 when his vehicle was struck in the rear.  At that time the CI did have any discomfort, but did report to sick call and was prescribed Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), Tylenol with codeine (acetaminophen, a pain reliever, and codeine, a narcotic), and Flexeril (cyclobenzaprine, a muscle relaxer).  Because of soreness and discomfort in the middle back and stiffness and soreness in his neck and low back, he sought chiropractic care.  Two days after the first accident, the CI was involved in an accident where he was hit from behind by another vehicle. He had increased pain in his middle back and immediate slight pain in the lower back.  Chiropractic care continued and he had minimal low back pain and persistent thoracic pain.  He denied any bowel or bladder problems.  

An MRI dated 25 March 2003 demonstrated normal thoracic kyphosis with loss of disc desiccation, as well as minimal disc space narrowing at the T6-7, T7-8, and T8-9 levels with a small central disc herniation at each of the levels mildly impressing upon the thecal sac at each level.  Radiographic (X-ray) studies of the thoracic spine in October 2003 noted an apparent mild dextroscoliosis of the upper thoracic spine and no sign of fracture was seen.  

At the 24 March 2004 MEB NARSUM examination, 9 months prior to separation, physical examination showed an antalgic and guarded posture and he was slightly hesitant in his gait.  He was able to forward flex to 20 centimeters (approximately 70-80 degrees, normal 90) from the floor.  Rotation to the left was approximately 50 degrees (normal 30) and the right was approximately 40 degrees.  There was no gross deformity.  He was tender to palpation about the thoracic spine between the shoulder blades.  The remainder of the examination showed no tenderness and was non-focal.  Neurovascular examination was normal.  Reflexes, motor strength, and sensation were normal.  The NARSUM examiner noted the CI was unable to return to work in a full duty status and was unable to work any longer than 10 to 14 minutes without getting up and moving about.  He was unable to run or participate in a Navy PRT (physical readiness test).  He walked slowly, but stated his distance was probably unlimited.  He also had trouble completing other duties, especially lifting.  

At the 10 August 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported thoracic spine pain with an intensity of about 6/10 (10 being the worst pain) for which he took analgesics on an as needed basis.  Physical examination showed a normal gait and the range of motion ROM of the lumbar spine was approximately 65 degrees of hyperextension; 35 degrees lateral bending and twisting were limited to about 35% of motion.  The VA Rating Document (VARD) dated 28 December 2006 indicated the examination of 10 August 2005 included ROM measurements for flexion of 85 degrees and a combine ROM of 190 degrees (normal 240).  There was some muscle spasm to palpation and no incapacitating episodes within the prior 12 months.  

The panel discussed whether the thoracic spine pain condition was unfitting.  The panel majority determined there was not a preponderance of evidence to change the not unfitting back condition to an unfitting condition since it was not specifically mentioned in the Non-Medical Assessment, the CI had good evaluation reports, and the condition did not interfere with his duty performance and he remained working in his primary specialty.  The panel minority; however, noted that the CI had been on 8 months of limited duty, was unable to return to a full duty status, was unable to work any longer than 10 to 14 minutes without getting up and moving about, and he was reassigned from sea duty to a support position on shore.  According to the panel majority there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation according to the panel majority.  After due deliberation, the panel majority concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right inferotemporal visual field defect condition and IAW VASRD §4.79 and VASRD 4.77, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended thoracic spine pain condition, the panel majority recommends no change from the PEB determination as not unfitting.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

Minority Opinion.  The CI wrote in his request for reconsideration that the injuries he sustained in the motor vehicle accidents resulted in his transfer from duty on a carrier to a shore command.  He further noted that his efforts to perform his duties were in vain even on shore duty.  He was unable to sit or stand for alternating period of 10 minutes.  

A note written by his chiropractor dated 24 August 2004 indicated the CI had been treated quite a bit in the clinic.  His low back pain and neck symptoms appeared to have responded moderately well to treatment with only slight residual discomfort remaining.  However, his middle back pain did not respond well, although he obtained significant relief with manipulation and other therapy modalities, but the relief did not appear to last more than 2 or 3 days.  Overall the pain was less, but not enough for the CI to function normally.  The chiropractor noted that the CI’s middle back injury, compounded by the scoliosis, appeared to create a significant disability not only in his work duties, but also in his activities of daily living.  The chiropractor then opined that if the CI did not have the vision loss, it was unlikely that he still would not be able to return to a ship or continue to discharge his duty to the U.S. Navy.  For the record sea duty is a special challenge.  Even small ships have many ladders that need to be climbed on a regular and continuous basis including board the ship, not infrequently while carrying equipment, or when moving during evolutions including general quarters.  That does not even take into account rough seas where movement about a ship requires balance and skill to avoid accidents or injuries.  

Despite 8 months of limited duty, the CI was unable to return to a full duty status and was unable to work any longer than 10 to 14 minutes without getting up and moving about.  Furthermore, the NMA indicated that “being non-worldwide assignable due to his medical condition is detrimental to his future in the Navy.”  While inability to deploy cannot be the sole reason to find the CI unfit, his back injuries and the residual consequences related thereto warranted his removal from the ship where he was potentially a danger to himself or to others if he could not move quickly and safely during any evolution including, but not limited to firefighting, working party participation, man overboard drills or an actual event, standing watch outside of his regular workspace, air operations, combat, or even physical fitness training.  

Furthermore, the CI’s physical findings correlate with his MRI in 2003, which showed loss of disc desiccation, as well as minimal disc space narrowing at the T6-7, T7-8, and T8-9 levels with a small central disc herniation at each of the levels mildly impressing upon the thecal sac at each level.  Therefore, there is no question that the CI should be found unfit despite the fact that the diagnosis was not added to his limited duty (LIMDU) documentation and the NMA, which was silent in regard to his back despite his attending chiropractic treatment sessions, although it listed that the CI was away from current duties for treatment, evaluation, and/or recuperation for 7 hours per week.  

Because the minority voter would find the CI unfit, a rating is warranted.  A 10% rating, but no higher, would be justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees), as reported on the VA examination, albeit 8 months post-separation, while at the NARSUM examination the CI forward flexed to approximately 20 cm from the floor , which rounds to about 85 degrees.  Although there was muscle spasm, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating is not justified.  

Therefore, the minority voter recommends the ROP be modified as follows:  In the matter of the contended thoracic spine pain condition, the panel agrees that it was unfitting and recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Inferotemporal Visual Field Defect	6080	10%	
Thoracic Spine Pain	5243	10%	
COMBINED	20%	

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

	
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	     				  Acting