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Torres v. Berryhill

United States District Court, E.D. Louisiana

August 27, 2018

JERRY LYNN TORRES
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION

         SECTION: “R”(1)

          JUDGE SARAH S. VANCE

          REPORT AND RECOMMENDATION

          JANIS VAN MEERVELD UNITED STATES MAGISTRATE JUDGE.

         The plaintiff, Jerry Lynn Torres, seeks judicial review, pursuant to Section 405(g) of the Social Security Act (the “Act”), of the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying his claim for supplemental security income (“SSI”) under Title XVI of the Act, 42 U.S.C. § 1381. The matter has been fully briefed on cross-motions for summary judgment. For the following reasons, IT IS RECOMMENDED that the Motion for Summary Judgment filed by the plaintiff (Rec. Doc. 14) be DENIED; and the Motion for Summary Judgment filed by the Commissioner (Rec. Doc. 15) be GRANTED.

         Procedural Background

         Mr. Torres applied for SSI on April 17, 2014, asserting a disability onset date of January 1, 2013. He alleged the following illnesses, injuries, or conditions: vision problems, bad stomach, and right kidney shutting down. On October 15, 2014, his claim was denied by the state agency. Mr. Torres obtained counsel and requested a hearing before an Administrative Law Judge (“ALJ”), which was held on February 25, 2016. On May 4, 2016, the ALJ issued an adverse decision. The Appeals Council denied review on August 11, 2017.

         On September 27, 2017, Mr. Torres filed a Complaint in federal court to review the Commissioner’s decision. (Rec. Doc. 1). The Commissioner answered and filed the administrative record. (Rec. Docs. 10, 11). The parties filed cross-motions for summary judgment. (Rec. Docs. 14, 15). Mr. Torres is represented by counsel.

         Evidence in the Record

         A hearing was held before the ALJ on February 25, 2016. Mr. Torres lived with his parents and his children aged 10 and 11 at the time of the hearing. R. at 42. Mr. Torres testified that he wore glasses as a child, but stopped wearing glasses after high school because he stopped going to the eye doctor. R. at 39-40. He testified that he got glasses again about eight months prior to the hearing. R. at 40. Mr. Torres testified that he does some cleaning and cooking around the house. R. at 42. Sometimes he takes his children fishing. R. at 42. He can take care of himself, bathe, dress, and shave, though he noted he did not use a razorblade. R. at 47.

         Mr. Torres testified that he had not worked at all since 2013, except for occasionally cutting a neighbor’s grass. R. at 41. During a telephone interview with the state agency in conjunction with his application for disability benefits Mr. Torres reported that he stopped working in October 2008 due to the conditions specified in his application (vision problems, bad stomach, and right kidney shutting down). R. at 112. He reported working in construction from 1998 through 2008 and as a stocker in a grocery store from 1999 through 2007. R. at 113.

         The ALJ asked why Mr. Torres had told the consultative examiner that he could read, watch TV, shop, and take public transit, if it cannot see at all. R. at 40. Mr. Torres said he does not take public transportation and that his mother drives him everywhere. R. at 40. He said the only time he reads is when he helps his children with their homework and he uses his eyeglasses and a magnifying glass to do so. R. at 40. He explained that sometimes he rides with his mother, who does the shopping. R. at 42-43. He said that he can watch TV because he does not sit far away and he has a 64 inch TV. R. at 45. Mr. Torres testified that he can walk outside without bumping into things, unless they are in his peripheral vision. R. at 45. He said he would trip on the sidewalk if it had a lip. R. at 45.

         Medical Records

         Mr. Torres only challenges the ALJ’s findings with regard to the extent of his visual limitations. Accordingly, the Court’s summary of medical records is limited to vision related medical records.

         A consultative examination was performed on August 4, 2014, by Dr. Gary F. Carroll with Internal Medicine Associates of New Orleans, LLC. R. at 220. Dr. Carroll noted that Mr. Torres does not have a driver’s license, but he is able to take standard public transportation. R. at 221. Dr. Carroll also noted that Mr. Torres performs household chores, reads, and watches television. R. at 221. Upon a review of systems, Dr. Carroll noted Mr. Torres has a history of myopia. R. at 221. Mr. Torres reported that he had not worn lenses or had an eye examination since childhood. R. at 221. Upon physical examination, Mr. Torres’ uncorrected visual acuity was measured at 20/160 bilaterally. R. at 222.

         Mr. Torres presented to Dr. de la Rua on October 2, 2014, for an eye examination. R. at 227. Dr. de la Rua filled out a Disability Determination Services Eye Examination Report. R. at 227. Mr. Torres had uncorrected visual acuity of 20/200 in the right eye and 20/CF (count fingers) in the left. R. at 227. With best correction, visual acuity was measured at 20/150 in the right eye. R. at 227. Dashes in the row for “left eye” indicate that the corrected vision in the left eye remained 20/CF. R. at 227. An SSA Kinetic test was performed, and the results were attached. R. at 228-29. In the next section of the form, Dr. de la Rua noted that Mr. Torres was cooperative, but that the test results were not valid. R at 227. His notes explain “ambulation/mobility observed in free space does not reflect or agree [with] severe field constrictions.” R. at 227. He added that the “situation may be clarified with [Visual Evoked Potential] testing.” R. at 227. Dr. de la Rua included no further explanation regarding the validity or invalidity of the test results. Despite his note regarding invalidity, Dr. de la Rua filled out the last portion of the form, asking whether the claimant can read fine print, read large print, handle and work with large objects, drive an automobile, operate machinery, avoid objects in workplace pathways, or avoid people approaching from the side. R. at 227. For all, he circled “no.” R. at 227. For “handle large objects” and “operate machinery” he put a question mark next to the “no” response. R. at 227.

         State agency examiner Dr. Jerome Medley reviewed the medical records in Mr. Torres’ disability benefits application and completed a case analysis on August 28, 2014. R. at 60. In the residual functional capacity assessment, Dr. Medley summarized Mr. Torres’ visual limitations as best vision of 20/150 in the right eye and CF (count fingers) in the left eye, a history of amblyopia, and severe constriction of visual fields on SSA kinetic testing exam. R. at 60. But Dr. Medley noted the exam of Mr. Torres’ eyes did not show any abnormalities to account for the poor vision or poor visual fields and the result of the consultative examination “were felt not to be valid.” R. at 60. Dr. Medley further noted that he called consultative examiner Dr. de la Rua, who “stated claimant was able to manipulate around the office without any problems. If his vision and such severe constriction of his fields were this bad, he would have had problems in a strange environment.” R. at 60. A case analysis form by Dr. Medley dated October 15, 2014, concludes “deny vision because of invalid findings.” R. at 230.

         While at the University Medical Center in New Orleans (“UMC”) on February 12, 2015, for evaluation of chronic kidney disease, Mr. Torres reported bilateral vision changes and stated that he has had vision difficulties since he was a child. R. at 259, 261. On February 23, 2015, he returned to UMC to establish care with a primary care physician. R. at 268. Chronic blurry vision was noted in the review of systems. R. at 269. However, the recommended plan focused on a renal work up, blood pressure medication, his abdominal pain, and his back pain, but not blurry vision. R. at 272.

         On December 10, 2015, Mr. Torres presented at the UMC for a hypertension eye screening. R. at 345. Goals of keeping blood pressure below 140/80 and cholesterol with LDL below 100 were discussed. R. at 347-48. He was referred to LSU Ophthalmology. R. at 348.

         Mr. Torres presented at the UMC Vision Center on February 15, 2016, to establish care. R. at 385. He complained of dry, itchy eyes. R. at 385. Mr. Torres received an eyeglasses prescription for .5 in the right eye and .75 in the left eye. R. at 232.

         Ten days later on February 25, 2016, Mr. Torres received an eyeglasses prescription for .25 in the right eye and .75 in the left eye from Dr. Dennis Muller with Eyedox. R. at 236. Dr. Muller also noted that Mr. Torres has “complete loss of inferior visual field” and recommended that he be examined for pituitary adenoma or other space taking lesion. R. at 237.

         Additional evidence that was not before the ALJ was submitted by Mr. Torres to the Appeals Council. Mr. Torres submitted additional records from his February 15, 2016, visit with the UMC Vision Center. R. at 30. He was diagnosed with bilateral amblyopia and poor vision. R. at 30. Uncorrected visual acuity in the right eye was 20/70-2 and 20/200 in the left. R. at 30. Final prescription was .5 for the right eye and .75 for the left eye. R. at 31.

         He also submitted additional records from his February 25, 2016, examination at Eyedox with Dr. Muller. R. at 27-28. Mr. Torres reported blurred vision at distance and near, peripheral vision, and dry eyes. R. at 27. Unaided visual acuities were recorded as 20/200 in both the left and right eyes. R. at 26. Final prescription assigned was .25 in his right eye, resulting in visual acuity of 20/50, and .75 in his left eye, resulting in visual acuity of 20/70. R. at 27-28. Upon examination, Dr. Muller noted bilateral visual field screening was normal. R. at 28. Impressions were noted as dry eye syndrome, hyperopia, and astigmatism. R. at 28.

         Mr. Torres also submitted records from a December 29, 2016, examination by Ophthalmologist Dr. Martin J. Schoenberger. Vision in his right eye was 20/200 and in his left eye was 20/400. R. at 9. Dr. Schoenberger wrote Mr. Torres an eyeglass prescription for � in the right eye and  in the left eye, with additional 225 in both. R. at 8. Dr. Schoenberger ordered a carotid ultrasound for optic neuropathy. R. at 12.

         On January 3, 2017, a carotid bilateral study was performed using B-mode and Doppler scanning. R. at 10. A history of ischemic optic neuropathy was noted. R. at 10. Impression ...


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