DEI Literature Review

Because patients who are underrepresented in medicine (URiM) are more likely to experience worse health and vision outcomes,¹ clinician-scientists continue to focus on diversity, equity, and inclusion (DEI) research.

DEI within the ophthalmic profession is equally of interest. Studies published in the last year have looked at gender, race, and other demographics in various ophthalmology education settings, including mentorship, leadership, and residency matching, among others, to assess where the field stands and where there remains room for improvement.

This article distills recent studies that have tracked DEI issues—as well as progress made—within ophthalmology, from the perspective of both patient care and the profession.

THE RELATIONSHIP BETWEEN PATIENT DEMOGRAPHICS AND…

Detection of IRDs

A study by Abuzaitoun et al sought to determine whether Black race was associated with the detection of pathological variants for inherited retinal diseases (IRDs) via genetic testing.² The results indicated a reduced likelihood of obtaining a conclusive genetic diagnosis among Black individuals compared with White individuals.

A total of 572 patients were divided into two groups based on racial identity: Black (n = 54) and non-Hispanic White (n = 518). Black race and older age were found to be independently associated with decreased odds of reaching a conclusive genetic test result. In one of the two databases used in the study, 44.4% of Black patients had a positive/likely positive test result, which was a significantly lower proportion compared with White patients (57.7%).²

These findings, the study authors concluded, highlight a growing concern over patient access to investigational therapies for IRDs. In addition, Black patients with an IRD may be disadvantaged in terms of proper prognostication, inheritance counseling, reproductive decision making, and eligibility for clinical trials due to the lower likelihood of obtaining a positive genetic test result.²

Retinal Detachment Severity at Presentation

Ong et al found that patients with adverse neighborhood-level social determinants of health present with more severe cases of rhegmatogenous retinal detachment (RRD).³ This retrospective cohort study included 700 adults who underwent primary repair of an uncomplicated RRD. Every decile increase in Area Deprivation Index (ADI), which indicates greater socioeconomic disadvantage, was associated with increased odds of presenting with a VA worse than 20/40 and fovea-involving RRD. Moreover, each $1,000 increase in per capita income was associated with lower odds of presenting with worse visual acuity, and every 1% increase in the percentage of workers who drove to work was associated with an increase in odds of presenting with worse vision and fovea-involving RRD. The study authors concluded that these findings suggest there are potential health benefits of implementing public policy changes to address the barriers faced by patients residing in disadvantaged neighborhoods to improve access to care and outcomes of RRD.

Quality of Diabetic Eye Care

Chaudhury et al looked at how social determinants of health (eg, health insurance, residence urbanicity, diabetes type, and diabetic retinopathy [DR]) affected how patients received eye care in accordance with established clinical practice guidelines.⁴ The complex results showed that certain factors affect patients differently according to race, while other factors were not associated with a difference in care.

Compared with those of the same race who lived in urban communities, Black and White patients with diabetes from rural communities had an 88% and 25% lower chance of having eye care visits, respectively. Black and White patients with worse disease had 4% and 5% higher odds of having an eye care appointment, respectively. Furthermore, Black patients with preexisting DR had 15% lower odds of having an eye care visit compared with those without preexisting DR, while White patients with preexisting DR had a 16% higher likelihood. Hispanic patients had 15% lower odds of eye care visits compared with non-Hispanic patients.

Not all factors affect all patients the same way, the study authors concluded. Several groups are at a particular risk of not receiving diabetic eye care in accordance with clinical practice guidelines (patients living in rural communities, Black patients with preexisting DR, and Hispanic patients), potentially leading to worse health and vision outcomes.

Likelihood of Proliferative Diabetic Retinopathy

A study by Yangyiran et al found that patients who live in neighborhoods with greater socioeconomic disadvantage and those who live farther from ophthalmology clinics have greater odds of developing proliferative DR (PDR).⁵

A total of 73,618 patients were included, and a significant relationship was observed between ADI quartile and distance from ophthalmology clinics. Among patients residing within 8 miles of an eye care clinic, those living in higher ADI quartiles had increased odds of PDR compared with those who lived in more advantaged areas. However, for patients living more than 8 miles away from a clinic, the odds of PDR were similar across all ADI quartiles; that is, patients in all ADI quartiles living more than 8 miles away from a clinic had greater odds of developing PDR compared with those of the same ADI quartile who lived within 8 miles of a clinic.

“Our study looked at the association between characteristics of patients’ residential neighborhoods (ie, how far they reside from ophthalmology clinics) and receiving a diagnosis of PDR at two major academic medical centers,” Cindy X. Cai, MD, one of the study authors, shared with Retina Today. “We found that patients who resided in neighborhoods with greater socioeconomic disadvantage and farther from ophthalmology clinics had greater odds of PDR. This suggests we should potentially focus DR screening on socioeconomically deprived and more distant neighborhoods to reduce vision loss from PDR.”

DEI WITHIN THE OPHTHALMOLOGY PROFESSION

Messaging Across Canadian Postgraduate Websites

To evaluate DEI in Canadian postgraduate medical education, Bondok et al analyzed 17 postgraduate medical education (PGME) websites’ messaging regarding DEI using 20 criteria across five domains: leadership and governance, recruitment, accommodations, community engagement, and pathways to entry. Applicants for residency programs encounter this information while researching PGME programs, which may influence recruitment and retention.⁶

The findings revealed a mean score of 8.65/20 in DEI performance (range, 4/20 - 13/20). Leadership and governance had the highest mean proportion of completed criteria (51%), and community engagement had the lowest (24%). Nine of the programs met at least half of the criteria, although regional trends emerged: Ontario and the Western Provinces scored significantly higher compared with Quebec, the Prairies, and the Atlantic region.

Overall, the commitment to DEI across PGME websites was variable. The regional differences suggest there are potential benefits of enhancing communication regarding best practices to support DEI initiatives throughout Canada, the authors concluded.

Trends Within US Academic Institutions

Tao et al analyzed race, ethnicity, and gender trends among US full-time academic ophthalmology faculty and department chairs from 1966 to 2021 in a study involving registrants of the Association of American Medical Colleges.⁷

The annual proportional change for women; minoritized race; and Hispanic, Latino, or Spanish ethnicity was +0.63%, +0.54%, and -0.01%, respectively. For department chairs from 1966 to 2021, the annual rate of change in the proportion of women; minoritized race; and Hispanic, Latino, or Spanish ethnicity was +0.32%, +0.34%, and +0.05%, respectively. In both faculty and department chairs, the proportion of URiM groups (ie, American Indian or Alaska Native, Black or African American, Hispanic, and Native Hawaiian or Other Pacific Islander) grew the least.⁷

Importance of Mentorship

Cote et al conducted a prospective study with ophthalmologist and trainees who were asked to fill out 10-item surveys focused on mentorship and career satisfaction. Female ophthalmologists reported experiencing significantly worse mentorship satisfaction and poorer quality of mentorship, as well as significantly lower income, worse job satisfaction, and lower rates of goal achievement and support toward achieving future goals. Notably, however, these career outcomes (except for income level) were partially mediated by mentorship score (mediation effect ranged from 29% to 68%).⁸ These data illustrate an intuitive relationship between mentorship and career success; therefore, providing quality mentorship for women in ophthalmology at all stages of education and professional development is crucial, the study authors concluded.

Inclusivity in Author Submission Guidelines

Tao et al evaluated the inclusivity of opthalmology journals’ author submission guidelines based on six criteria: 1) included gender-inclusive language; 2) recommended use of gender-inclusive language; 3) distinguished sex from gender; 4) provided educational resources on gender-inclusive language; 5) provided a policy allowing name changes; and 6) gave a statement of commitment to inclusivity. The study authors considered a journal to be “inclusive” if it met at least one of these six criteria.⁹ Of 94 journals evaluated, 29.8% were rated as inclusive; interestingly, these journals also had a higher relative impact factor, citations, and article influence scores compared with noninclusive journals. The three most common criteria met were having an inclusivity statement (71.4%), defining sex versus gender (67.9%), and providing additional resources on gender reporting for authors (60.7%).⁹

The study authors concluded by suggesting the potential value in journals updating their author submission guidelines to use more gender-inclusive language.⁹

Geographic Trends Among Ophthalmic Subspecialty Surgeons

A study by Ahmed et al identified a gap in ophthalmic care in rural areas of the United States, where there resides a lower proportion of specialty surgeons versus patients requiring services.¹⁰ The study included Medicare patients and surgeons performing specialized procedures between 2012 and 2022. The researchers evaluated 13,526 ophthalmic surgery specialists: 2,540 cornea (18.5%), 3,676 glaucoma (26.8%), 1,951 oculoplastic (14.2%), 4,123 retina (30%), and 1,236 strabismus (9%). Across these specialities, 5.6% lived in rural areas compared with 17.4% of patients. Several groups were identified as less likely to practice in rural areas, including female surgeons, surgeons in the Northeast and the West, and recent graduates.

Diversity Among Resident Applicants Versus Medical Students

Paracha et al compared the diversity of ophthalmology residency applications and matriculants with that of graduating medical students and found that certain groups were significantly underrepresented in residency.¹¹

The study used representation quotients (RQ) from reports by the Association of University Professors of Ophthalmology and San Francisco Match, along with demographic data from the Association of American Medical Colleges. An RQ is a metric of DEI that divides a racial, ethnic, or gender group’s proportion in a specific population by its proportion in a larger population. Black individuals had the lowest mean RQ among residency applicants and matriculants, and regression analysis showed that female ophthalmology residency applicants and matriculants experienced decreased representation compared with medical student populations, while men experienced increased representation. Moreover, Black and Hispanic individuals experienced a decrease from residency application to matriculation. This study demonstrates that underrepresentation of female, Black, and Hispanic individuals remains persistent in ophthalmology residency programs and that more URiM applicants does not always translate to increased matriculation rates of these groups.

WHEN WE KNOW BETTER, WE DO BETTER

Although progress has been made in DEI within the profession, these recent studies highlight room for growth and the need to support a better environment for URiM patients and ophthalmologists.

1. Elam AR, Tseng VL, Rodriguez TM, Mike EV, Warren AK, Coleman AL; American Academy of Ophthalmology Taskforce on Disparities in Eye Care. Disparities in vision health and eye care. Ophthalmology. 2022;129(10):e89-e113.

2. Abuzaitoun RO, Branham KH, Lacy GD, et al. Racial disparities in genetic detection rates for inherited retinal diseases. JAMA Ophthalmol. 2024;142(12):1150-1156.

3. Ong SS, Tran D, Westlund E, et al. Neighborhood-level social determinants of health and presenting characteristics for rhegmatogenous retinal detachments. JAMA Ophthalmol. 2024;142(9):845-854.

4. Chaudhury AS, Ige M, Marwah S, et al; Sight Outcomes Research Collaborative (SOURCE) Consortium. Race, social determinants of health, and the quality of diabetic eye care. JAMA Ophthalmol. 2024;142(10):961-970.

5. Xie WY, Rustam Z, Tran D, et al. Association of neighborhood socioeconomic disadvantage with proliferative diabetic retinopathy. Ophthalmol Retina. 2024:S2468-6530(24)00483-4.

6. Bondok M, Bondok M, Martel L, Law C. Evaluating equity, diversity, and inclusion in Canadian Postgraduate Medical Education: A cross-sectional analysis of online content. PLoS One. 2024;19(8):e0307584.

7. Tao BK, Ding J, Ing EB, et al. Gender, race, and ethnicity of US academic ophthalmology faculty and department chairs from 1966 to 2021. JAMA Ophthalmol. 2024;142(8):742-748.

8. Cote SL, Nguyen A, Berry JL, et al. Gender disparities in mentorship and career outcomes in Ophthalmology. J Womens Health (Larchmt). 2024;33(8):1120-1127.

9. Tao BK, Xie JS, Leong R, et al. Gender inclusivity of ophthalmology journal submission guidelines and associated research metrics. Eur J Ophthalmol. 2025;35(1):126-132.

10. Ahmed A, Ali M, Dun C, Cai CX, Makary MA, Woreta FA. Geographic distribution of US ophthalmic surgical subspecialists. [Published online ahead of print January 2, 2025]. JAMA Ophthalmol.

11, Paracha SS, Williams SA, Shamshad A, Persad-Paisley EM, Migliori ME. Representation quotients to examine diversity in ophthalmology residency applicants and matriculants [published online ahead of print January 16, 2025]. JAMA Ophthalmol.