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was the best of times. It was the worst of times.” Charles Dickens classic opening to A Tale of Two Cites (1859) might well apply to today’s glaucoma patient. On one hand, with today’s exquisitely-accurate diagnostic instruments and new management procedures, diagnosis is easier and treatment is better than ever before. On the other hand, up to 50% of current patients with glaucoma do not know they have the disease1 and many practitioners continue to use an intraocular pressure (IOP) and cup-to-disc (C/D) ratio approach to diagnosis. 2 However, some researchers are working with a systems-approach to help clinicians face the difficult task of deciding what action (risk assessment, follow closely, or consider therapy) to take for patients who may have openangle glaucoma with only subtle signs of damage.3 In this paper, we address the issue of refining decisions of which primary care patients to screen for glaucoma. Using currently available instrumentation and clinical research, we provide normative data on specific physical ocular structures resulting in an extension for primary care examination that promises more accurate identification of which primary eye care patients should be screened for glaucoma, bringing more patients with glaucoma closer to “the best of times”. With introduction of the ophthalmoscope (1854), glaucoma came to be defined as an ocular disease characterized by optic nerve damage with associated elevated intraocular pressure.4,5,6 Glaucoma is now considered as a group of ocular diseases, often accompanied by elevated intraocular pressure, that cause progressive optic nerve atrophy and blindness.7 In most “I

Refining decisions on which primary care patients to screen for glaucoma