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Nathan R. v. Saul

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

July 15, 2019

NATHAN R., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.


          Gabriel A. Fuentes Magistrate Judge

         Plaintiff, Nathan R.[3] ("Plaintiff) has moved for summary judgment seeking reversal or remand of the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying his claim for Supplemental Security Income ("SSI"). (D.E. 16: Pl.'s Mot. for Sum. J. and Mem. in Support of Sum. J.) The Commissioner has filed her own motion seeking affirmance of the decision denying benefits (D.E. 24: Def.'s Mem. in Support of Sum. J.), and claimant has filed a reply. (D.E. 26.) For the following reasons, Plaintiffs motion for remand is granted and the Commissioner's motion is denied.

         I. Background

         Plaintiff filed for SSI on May 29, 2015, claiming an onset date of May 19, 2015. (R. 71.) In his application for benefits, Plaintiff claimed he suffered from right eye vision loss, cataract due to severe asthma, and allergies. (Id.) After his claims were denied initially on October 16, 2015 and on reconsideration on January 10, 2016, Plaintiff participated in a hearing before an Administrative Law Judge ("ALJ") on March 15, 2017. (R.79, 90.) On April 11, 2017, the ALJ denied benefits and the Appeals Council affirmed the denial on February 1, 2018, making it the final opinion of the Commissioner. (R. 4-6, 21-31.) See 20 C.F.R. § 404.981; Lanigan v. Berryhill, 865 F.3d 558, 563 (7th Cir. 2017).

         A. Medical Evidence[4]

         Plaintiff had surgery in 2009 to repair cataracts in both eyes; the cataracts were likely a result of long-term use of steroid medication for his asthma, which was diagnosed when he was 9 months old. (R. 396.) Surgery on the right eye was only partly successful, and Plaintiffs eyesight in that eye continued to deteriorate. (R. 384). In December 2014, Plaintiff visited Cook County Health Systems complaining of redness and discharge from his right eye, as well as pain when he closed it. (R. 351-52.) He was initially diagnosed with conjunctivitis and urged to make an ophthalmology appointment. (Id.) After visiting the ophthalmologist in January and February 2015, Plaintiff experienced a detached retina in his right eye on May 19, 2015, and lost all sight in that eye as a result. (R. 43, 372, 387.) Plaintiffs left eye has near normal vision, assessed as 20/30 or 20/40 at various appointments. (R. 385, 396.)

         While being treated for problems related to his detached retina, Plaintiff also had regular treatment for asthma and allergies. Between March 2014 and December 2015, Plaintiff had appointments approximately every three months with Byung Yu, M.D., at Cook County Health Systems. (R. 342-78.) Records from these visits reflect that Plaintiffs asthma was generally well-controlled with medication. (R. 342.) Plaintiffs allergies included atopic dermatitis, allergic rhinitis, uveitis[5] and food allergies, all of which primarily manifested as rashes on his skin and soreness and discharge on and around his eyes and eyelids. (R. 492.) He used a number of topical, inhaled, and ingested medications to treat his symptoms, and the medical record shows that the severity of his symptoms, including dry, burning and itchy skin, redness, watery eyes, sore and infected eyelids and coughing fluctuated from appointment to appointment. (Id. 343, 347-70.)

         On July 27, 2015, Plaintiff was examined by Commission doctor Carolyn Hildreth, M.D. (R. 384.) She described his 2009 cataract surgery and right eye vision loss, and assessed him as blind in the right eye, with 20/40 vision in the left. (R. 393.) Dr. Hildreth also noted Plaintiffs history of asthma, and that he had not required emergency room visit or use of a nebulizer for the previous several years. (R. 387.)

         On August 12, 2015, Plaintiff had an ophthalmology appointment with Zachary Seagrave, M.D., because of redness and discharge from his right eye. (R. 442.) Dr. Seagrave diagnosed plaintiff with atopic dermatitis and severe MGD[6]; he increased one of Plaintiff s eye-drop dosages to every three hours and added a new ointment for dry areas on his skin. (R. 444.) That same day, plaintiff also had a dermatology appointment, which noted active atopic dermatitis on his arms and upper back, and an eye infection, which was being treated by the ophthalmology department. (R. 459-61.)

         Plaintiff underwent an ophthalmology consultative examination on August 18, 2015. (R. 396.) David Hillman, M.D., noted that Plaintiff had been born with cataracts in both eyes, but that his vision did not begin to deteriorate until 2008, leading to his surgery in 2009. (Id.) Dr. Hillman found that Plaintiff could perceive light, but nothing else from his right eye, and that his left eye had 20/30 vision (Id.) On September 4, 2015, Plaintiff had an ophthalmology appointment to follow up on problems he was having with right eye redness and discharge. (R. 401-05.) Dr. Seagrave listed 19 different medications (topical, inhaled and ingested) that Plaintiff was currently prescribed to treat his asthma, allergies, and allergy-related eye problems. With respect to Plaintiffs eyes, Dr. Seagrave wrote that Plaintiffs redness and discharge in his right eye was "improved;" he noted plaintiff was being treated for "atopic dermatitis with severe blepharitis and dry eye."[7] (R. 401, 476.) At the time, Plaintiff was still using steroid eye drops four times per day as well as three other topical treatments as needed, and was also being treated by a dermatologist. (R. 401-04.)

         On September 17, 2015, Myrtle Mason, M.D., M.P.H., performed a psychiatric examination on plaintiff for the Commission. (R. 409.) Plaintiff reported that his chief complaint was loss of vision in his right eye, and that it was upsetting to have limited vision. (R. 410.) Dr. Mason noted that Plaintiff was bothered by feelings of insecurity, but her examination was mostly unremarkable. (R. 409-13). She diagnosed him with an adjustment disorder, NOS. (R. 413.)

         Commission doctor Calixto Aquino, M.D., reviewed the medical record on October 15, 2015 and opined that plaintiffs only impairment was right-eye blindness. Because Plaintiffs left-eye vision was essentially normal, his vision overall was non-severe; thus Dr. Aquino opined that Plaintiff did not have a severe impairment. (R. 75.) Dr. Aquino also opined that Plaintiffs remaining impairments - cataracts, asthma, and affective disorder - were non-severe. (R. 76.) On reconsideration on January 10, 2016, Jerda Riley, M.D. explained that Plaintiffs eye impairment was non-severe because his left eye had nearly normal vision (20/30). Therefore, Dr. Riley opined that Plaintiff had a Residual Functional Capacity ("RFC"): to lift 50 pounds occasionally and 30 pounds frequently, and to avoid activities requiring even moderate exposure to operating moving vehicles, working at hazardous unprotected heights, and machines with open areas, conveyors, machines with blades or combustible parts, or machines with parts that can engage the body. (R. 84.)

         Plaintiff continued to visit Cook County Health Systems monthly for follow-up appointments related to his eye problems and allergies; he often visited both the ophthalmology and dermatology departments on the same day.[8] On November 18, 2015, he had a follow-up dermatology appointment that noted improvement in his atopic dermatitis. (R. 521.) On December 1, 2015, Dr. Byung continued to prescribe multiple types of eye drops and topical ointments to be applied around Plaintiffs eyes and his skin throughout the day. (R. 535-55.) On March 4, 2016, Plaintiff had another check of his eyelids. Justin Bloomberg, D.O., noted that Plaintiffs right-eye redness and discharge were improved; the doctor reiterated Plaintiffs diagnosis with severe MGD, blepharitis, and atopic dermatitis affecting his eyelids, as well as uveitis in his right eye. (R. 583-85.)

         On March 14, 2016, James Moy, M.D., of Stroger Hospital, wrote a note that Plaintiff "is blind in one eye and has decreased vision in his other eye." (R. 764.) In an undated note, Dr. Bloomberg wrote that Plaintiff "has a history of chronic eye problems in the right eye arising from retinal detachment, as well as skin problems around the eye related to allergies, requiring multiple applications of medicines in the eye daily. The eye drains throughout the day, and will require him to give attention to his eyes frequently. However he is able to fully participate in unrestricted work and has normal visual function in his left eye." (R. 765.) In another undated note, Dr. Seagrave wrote that Plaintiff was being treated for atopic dermatitis with severe blepharitis and dry eye. (R. 766.) The note also states that at the time, Plaintiff was using a steroid eye drop four times per day, an ointment and an antibiotic, and that he had a very poor visual prognosis of the right eye. (Id.)

         At an appointment on May 18, 2016, Plaintiff was temporarily prescribed a new topical ointment for a flare-up of atopic dermatitis on his face; he complained of swelling of his eyelids and red, itchy skin on his face. (R. 630-31.) He also continued to be prescribed four types of eyedrops to use between two and four times per day as well as a number of topical and inhaled medications. (R. 644-645.) By the time of Plaintiff s next appointment in June 2016, the flare-up was improved, but he had Assuring around his right lower eyelid and other skin rashes on his face and trunk. (R. 648-49.) On November 4, 2016, Plaintiff had an ophthalmology appointment with Dr. Bloomberg, who continued Plaintiffs regimen of four different prescriptions for eye drops, two applied twice per day, one applied four times per day, and one applied every three hours. (R. 416-17.)

         On February 22, 2017, Plaintiff underwent a psychiatric evaluation by Mark Amdur, M.D., at the request of plaintiff s attorney. (R. 432.) Plaintiff denied having any problems with nerves, mental issues, learning issues, or behavioral problems. (R. 433). When asked a standard question designed to elicit obsessive-compulsive symptoms, Plaintiff stated that he had a habit of talking to himself when alone to help him remember things he may have forgotten; Dr. Amdur characterized this behavior as either "an obsessive or autistic feature." (Id.) Dr. Amdur also noted that plaintiff rubbed his face repeatedly during the examination. (Id.). Dr. Amdur noted that both Plaintiff and his mother attributed his limitations to his vision issues, but Dr. Amdur explained that he could not assess the severity of plaintiffs visual impairments. (Id.) Instead, Dr. Amdur identified cognitive and austism spectrum symptoms including blunted affect, inattentiveness, minimal socializing, poor hygiene and grooming, illogicality, comprehension problems and visuospatial problems, in addition to plaintiffs habit of talking to himself. (Id.)

         B. Educational History

         Plaintiff graduated from high school in 2007. (R. 37.) He received special education services beginning in the first grade, although the record contains information only about his educational history for the 10th through 12th grades. (Id.) Starting in the 10th grade, Plaintiff received special education services because of learning disabilities; 60 percent to 80 percent of Plaintiffs special education services were provided within the regular classroom. (R. 260, 269.) Notes from Plaintiffs high school individualized education plan ("IEP") describe him as conscientious and respectful, and they note that his teachers were pleased with his academic and social progress. (R. 283.)

         In 2008, Plaintiff completed a certificate in pharmacy tech from Everest College. (R. 758, 770.) Between 2007 and 2010 he worked as in materials management and then as a pharmacy technician, first at a Walgreens and then at Provident Hospital; he was unable to continue working in this job after his eyesight deteriorated. (R. 54, 755.)[9] He last worked in 2010. (Id.) From December 2016 to December 2017, Plaintiff worked with a counselor from the Illinois Department of Human Services to try to find a job. (R. 421-24). In explaining Plaintiffs work limitations, his counselor described him as blind in one eye and needing safe work conditions away from pollen, mold, dust, stress, carpeted areas or pets, and also that he needed extended time to complete work and learned best through visual aids. (R. 425.) Notes from Plaintiffs initial interview with the Illinois Division of ...

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