We appreciate both the interest in our manuscript and the comments made by our colleagues, and we would like to take this opportunity to respond. First, we did not conclude that an afferent pupillary defect (APD) was not a helpful tool for any glaucoma screening; in truth, it may inexpensively help to distinguish normal cases from abnormal ones. An APD is relatively nonspecific and may be caused by a number of conditions other than glaucoma. However, in a population-based screening situation, such as ours, with variable lighting and flashlight conditions and with a large number of subjects, its sensitivity and specificity suggest that it is not a worthwhile test for screening specifically for glaucoma. In summary, our findings suggested that pupil examination by non-medical trained personnel in a population-based setting in a developing community may not be appropriate to suspect optic nerve pathology or glaucoma.
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