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Heitkam v. Berryhill

United States District Court, N.D. Illinois, Western Division

July 25, 2017

Shirley J. Heitkam Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, [1] Defendant.


          Iain D. Johnston Magistrate Judge

         Plaintiff Shirley J. Heitkam applied for Social Security disability benefits in 2012, when she was in her mid-fifties. She alleged that back, hip, feet, and other body pains from fibromyalgia and arthritis, and obesity make it difficult to walk, stand, or even sit for sustained periods. She allegedly spends much of her day in a recliner with her feet elevated. These conditions also cause her hands to become sore after prolonged use. She has histoplasmosis, a fungal infection, that led to a partial loss of vision in her right eye. Because of this limitation, she claims to get headaches after 10 to 15 minutes of reading or looking at a computer screen. The latter assertion is critical. Given her age and other factors under Social Security disability regulations, the sole issue is whether she could work as a data entry clerk, a job requiring typing and working at a computer screen. It was the only one of her past relevant jobs at the sedentary level and, thus, the only one of those jobs she could possibly do now.

         The administrative law judge (“ALJ”) held two hearings, with a different doctor and vocational expert testifying at each. Although these experts opined about several issues, the eye issue received the most attention. There was much back and forth about how to describe this particular impairment and what limitations, if any, it imposed. In fact, it appears a second hearing was held to address this particular issue. In addition to the hearing testimony, plaintiff's treating ophthalmologist, Dr. Suresh Chandra, submitted several opinion letters. In a written decision, the ALJ found that plaintiff's eye (and other) problems would not prevent her from working full-time as a data entry clerk. The ALJ found (among other things) that the two testifying doctors were more credible than plaintiff's treating doctor. Plaintiff now seeks a remand, raising a plethora of arguments attacking almost all aspects of the decision. Although this Court finds that many of these arguments would not warrant a remand on their own, the Court concludes that a remand is required based largely on the unresolved eye issue.

         To understand this issue, which will be the focus of this opinion, it will be helpful to chronicle at some length how it was addressed in the two hearings. The hearings provide a peek behind the curtain of the ALJ's reasoning. These hearings contain more detail and analysis than was included in the ALJ's decision, which glosses over certain questions raised in the hearings.

         The first hearing was held on May 5, 2014. Plaintiff testified that she “cannot [] stare at a computer screen for hours on end” and that she gets “headaches in the back of [her] head if [she looks] at one thing too long.” R. 62. She described the problem as being a strain on her left, or “good, ” eye that resulted from her not being able to fully or properly focus with the her right, or “bad, ” eye. R. 69. This problem was one reason she quit her last job as a bank teller in 2007. She stated that, because of the eye problems, she had to double and triple check deposit and cash back amounts.

         The ALJ called Dr. Gilberto Munoz, whose specialty is listed as “Family Practice, ” to testify as a medical expert. R. 147. He identified plaintiff's impairments as follows: “Fibromyalgia, hypertension, chronic kidney disease, right eye blindness, bilateral hip pain, and low back pain.” R. 73. He opined that plaintiff had the residual functional capacity (“RFC”) to do sedentary work subject to various restrictions. Relevant to the eye problems, plaintiff could not “drive for defensive purposes, ” could not work in any “safety sensitive positions, ” and could not be around heavy machinery or work at heights. R. 74. The ALJ then asked whether plaintiff would “be limited to monocular vision.”[2] Id. Dr. Munoz answered that, “[y]es, she is, but her doctor diagnosed 20/20 vision.” Id. The ALJ asked about allegations of headaches from “us[ing] that good eye to read the computer” and whether that was “a possibility.” R. 74. Dr. Munoz answered with only the terse comment that this possibility was “[v]ery unlikely.” Id. Like Bartleby the Scrivener, Dr. Munoz did not offer an explanation for this conclusion, nor did he express any doubts or qualifications.

         Recognizing this explanatory gap, plaintiff's counsel later in the hearing probed further. In the following colloquy, counsel elicited at least a partial explanation, although it is still one that (to this Court's layperson eyes) is not entirely clear:

Q Wouldn't you agree, Doctor, that the headaches and the eye strain due to the use of the one eye to focus on a computer or on reading would cause-I mean, could be caused by this histoplasmosis?
A People with monocular vision with her case, they have problem with depth perception. Some objects are not the same, but that wouldn't be an issue because for the computer she should be okay.
Q She'd be able to use a computer eight hours a day without any unscheduled breaks and not have these symptoms? Is that what you're saying?
A No, the eye on the left is perfect. It's 20/20. Actually, it's better than average for her age.
Q I'm talking about the eye strain causing headaches, the eye strain of using one eye to do -
A Which eye would feel strain? In order to strain your eye, you have to have vision.
Q The right eye is the eye that has no sight at all. The left eye is what she's using normally and then to compensate for the lack of the right eye and she's saying that that causes her eye strain to the point that she has to take these frequent breaks. Wouldn't that be reasonably consistent with her condition?
A I feel that you're asking me if I find an explanation for that and I tell you I didn't. I know that she has monocular vision. I am admitting to that. On her left eye, she has perfect vision on the left eye. I don't know how [you can] strain your good eye if it's normal.
Q You're saying you couldn't get eye strain from using your eye, using one eye to do computer work eight hours a day? That's impossible to get eye strain that way?
A You wouldn't have to deal with it if it is normal. You get eye strain in your eye [that] doesn't work. That one works perfectly.
ALJ: I think what he's saying is he can't explain what it is.

R. 75-76. It is worth pausing to note several points. The precise issue plaintiff's counsel focused on initially is whether headaches “could be” caused by the histoplasmosis-in other words, whether they were possible. Another point is that Dr. Munoz introduced the concept of depth perception as being relevant to the analysis. Another emerging question suggested by this exchange is the relevance of a single eyechart test (e.g. “20/20 vision” in one eye) to the broader question of whether headaches could result from using only that eye for eight hours or so of typing in a day.

         The next witness was a vocational expert, Richard Fisher. His testimony was brief. The ALJ asked him two hypothetical questions. The first question was based on Dr. Munoz's RFC, and asked whether a person with plaintiff's age, education, and work experience, who was limited to “sedentary work, except we have occasional postural and monocular vision” and who was limited to “safety sensitive positions” and “no unprotected heights, no dangerous moving machinery, ” would be able to do her past relevant work. R. 77. Mr. Fisher stated that plaintiff could work in her prior job as a data entry clerk. Mr. Fisher did not discuss what the specific duties of this job were. The second question added the qualification that plaintiff would need to take a 5 to 10 minute break every 20 minutes, a limitation presumably designed to account for the alleged eyestrain. Dr. Fisher opined that this qualification would eliminate all work for which she was qualified. At this point, plaintiff's attorney stated that he wanted “to get a medical source statement from the ophthalmologist.” R. 77. The following colloquy ensued:

ALJ: Okay. Make sure any significant findings I can understand, okay?
ATTY: Okay.
ALJ: I have a little trouble with ophthalmologists. [] They throw a lot of figures at me which I don't understand.
ATTY: No, I'm going to ask him about the eye strain and how that's reasonably consistent with her problem.

R. 78.

         On June 4, 2014, plaintiff submitted a letter from Dr. Chandra, which ...

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