Skin Color Representation in Ophthalmology Textbooks

Objective: Inadequate diversity in dermatologic images has been associated with diagnostic delays and poorer health outcomes. This underrepresentation of darker skin tones has also been demonstrated across various fields of medicine, including rheumatology, urology, and in the COVID-19 pandemic. The distribution of skin tones has not been examined in educational ophthalmology texts. The authors aimed to quantify the representation of skin tones across three leading ophthalmology textbooks. Methods: Two independent investigators utilized the Fitzpatrick’s skin phototype scale to code images containing skin as either “light” (Fitz. I–IV) or “dark” (Fitz. V–VI) in three fundamental ophthalmology textbooks: Clinical Ophthalmology (Salmon and Kanski), Ophthalmology (Yanoff and Duker), and the 13 Basic and Clinical Science Course texts by the American Academy of Ophthalmology. Images without discernible skin color were excluded. Results: Of the 9766 images reviewed, 2305 images met inclusion criteria. The three textbooks combined were found to have 2123 (92.1%) images of light skin tones and 182 images (7.9%) of dark skin tones. When compared to national data that found 12.6% of individuals to have dark skin tones, the proportion of images with darker skin tones in ophthalmology textbooks was statistically significantly lower (χ²_corr(1, N = 4996) = 211.7, p < 0.001). Conclusions: Darker skin tones are statistically significantly underrepresented in textbooks that are central to education of trainees in ophthalmology. Acknowledgement and inclusion of skin tone diversity in ophthalmology educational materials are necessary to ensure that physicians in the field are equipped with the knowledge and training to provide the highest level of care to all patients.