Diamonds in the Rough

The conversation around women’s representation in ophthalmology has shifted from whispers to thunderous debates at global conferences and symposia. Society is evolving, and the rising tide of awareness has delivered real change.

On the bright side, the profession is nearing a balance in ophthalmology training, with women comprising 35–45% of residents.¹ This surge in female applicants to medical schools signals a transformative era. A retrospective study in Ophthalmology revealed female representation in US ophthalmological societies skyrocketed from 29% in 2000 to 41% in 2020—a trend mirrored around the globe.²

Yet, the path remains steep. Despite these gains, only 20–30% of specialised ophthalmologists are women. An invisible bottleneck stifles their career advancement, with many struggling to break into surgical specialties or ascend to leadership roles. While the glass ceiling persists, new strategies are emerging to bridge the gap and foster a more inclusive field.

The challenges women still face

Like other surgical specialties, ophthalmology battles a significant gender gap in leadership. “Progress is evident, but women are still outnumbered—we still often see panel discussions where only one out of five or six speakers is a woman,” said Nivine Woods, president of Ophthalmic World Leaders (OWL).

Even though women have led many societies in recent years—including the ESCRS with Professor Filomena Ribeiro—women role models are still a minority compared to their male counterparts. Also, fewer of them complete their surgical training, establishing themselves as surgeons.

“There are certain areas where women are massively underrepresented, like refractive surgery as well as retinal surgery, and a little bit in cataract surgery,” said Sorcha Ní Dhubhghaill MD, PhD, Head of Department, Ophthalmology, at the Brussels University Hospital (UZ Brussel).

Women face more career obstacles than their male counterparts, especially during residency training, as the programmes are tough, demanding, and require a lot of personal sacrifices to achieve this higher level of training. Being in their late 20s or early 30s, an age in which many aspects of one’s future are determined, it is sometimes difficult to balance career and private life, making these decisions particularly tough.

According to Artemis Matsou MD, ophthalmic surgeon at Queen Victoria Hospital, East Grinstead, UK, this a multifactorial issue with two main roots: how the training programmes are structured and the need of some women to balance the extra pressure of pregnancy, motherhood, or family responsibilities.

“Some women may have been discouraged from pursuing a very surgery-heavy path [because the] training is very intense,” she stressed. “It takes away a lot of personal time and has an impact on someone who has a family. The structure of such programmes does not accommodate that; they are not really family or women friendly.”

Male residents do not usually feel the same burden, even if times are changing, with new generations of ophthalmologists more concerned about families and work-life balance. Yet it is still mainly women making the tough decision of renouncing their aspirations, with no equal opportunities discouraging this.

Harassment and bullying

Balance between work and private life is not the only reason women are discouraged or led to interrupt their advancements. Women unfortunately suffer more unwelcome and uncomfortable comments that can ruin a workday or performance in the OR, microaggressions, physical and psychological harassment and bullying, as well as being affected by unconscious bias, even from patients.

Women themselves could sometimes have implicit biases about their colleagues triggered by competition, jealousy, or the stereotypes shaped by social norms.

“We all have implicit biases. It is like a shadow—it never goes away and it never gets acknowledged,” Dr Matsou said.

These biases extend to the operating theatre, as women are generally still thought to be less capable than men in performing surgery and receive fewer opportunities.

“In countless fields—from surgeons and engineers to electricians and hairdressers—we see a deeply ingrained belief that men are inherently more capable,” Nivine Woods explained. “As a result, it takes a lot more effort, determination, and resilience for women—not only to prove their worth, but to shatter preconceived notions.”

As Professor Ní Dhubhghaill underlined, even women in higher positions are still required to demonstrate their capabilities more than their male colleagues, adapting themselves to situations. “We do not have the luxury to be unprepared, emotional, or not ready.”

This constant struggle—the fear of losing opportunities, the disadvantages, and the vulnerability—is difficult to overcome, she said, advocating for real and sustained solutions to take place, and not only some sporadic symposia or courses on the subject.

Catalysts for change

While change is structural and takes time, some solutions can help speed up the process. First, continuing to raise awareness is crucial because, as Dr Matsou noted, it should not be assumed that everyone knows or understands the situation for women in ophthalmology. Open discussions are very important for raising awareness, and the ESCRS is among the leaders providing such an avenue. Created by Prof Ribeiro and including Dr Matsou and Prof Ní Dhubhghaill as members, the ESCRS Building Our Sustainable Society (BoSS) programme maintains open discussion as a primary goal.

Collaboration with organisations like OWL is essential for building structured mentorship programmes and advocating for more inclusive policies. Women need support from institutions and scientific societies to create equal opportunities, make choices, and minimise the sacrifices that sometimes weigh on women’s shoulders.

Societies need to reflect on their overt and implicit biases to deconstruct them and place solid defence mechanisms from harassment. Importantly, male colleagues must be included in the discussions to advance the cause. For example, BoSS is open to everybody, with male leaders among the main team, and OWL rebranded from Ophthalmic Women Leaders to Ophthalmic World Leaders to reflect this inclusivity. According to both groups, men can be crucial sponsors, mentors, and drivers of change alongside women.

New technologies could serve well in this regard, as apart from quickly connecting people all around the world, technology offers more opportunities—such as surgical training, thanks to the implementation of surgical simulators, as Prof Ní Dhubhghaill pointed out.

Mentorship has been recognised as another powerful tool to foster this change. It constitutes a continuous and sustained exchange between the mentor and the mentored, passing knowledge, contacts, and networks. In a competitive environment such as ophthalmology, finding a mentor could open many doors for ambitious people to unlock their full potential and shape future role models, leaders, and mentors.

“Mentors are not only effective, but they are also transformative,” Dr Matsou said. “It is a healthy cycle, being mentored and giving back. Having structured mentorship programmes is very significant, and ESCRS is providing that now through the BoSS platform.”

Mentorship is good not only for females but for male ophthalmologists as well, to shape a more desirable society. Being a mentor is no easy job, but Prof Ní Dhubhghaill believes it is worth it in the long run.

“We, as mentors, need to be sure our juniors are better than we are, which is how the evolution of the medical field needs to be,” she observed.

A bright future ahead

Despite improvements, much work remains. Ignoring the current disparities would squander opportunities for the next generation of female ophthalmologists, impacting research and patient care. “Women in ophthalmology are like diamonds in the rough—they’re brilliant, but it takes a bit of time and work to uncover,” Nivine Woods concluded. “With time and dedication, we can unveil this hidden treasure and cultivate the vibrant, inclusive future we all envision.”

Nivine Woods PharmD, MBA is President of Ophthalmic World Leaders (OWL), US.

Sorcha Ní Dhubhghaill MBBCh, BaO, PhD, Dip (stats), FEBO, FEBOS-CR, MRCSI(ophth) is Head of Department, Ophthalmology, at the Brussels University Hospital (UZ Brussel), Belgium. sorcha.ni.dhubhghaill@uzbrussel.be

Artemis Matsou MD, MRCP(UK), FEBOS-CR, FEBO, PgDip CRS is ophthalmic surgeon at Queen Victoria Hospital, East Grinstead, UK. art.matsou@gmail.com

1. Azad A D, et al. “Representation of Women in Ophthalmology Subspecialty Societies over 20 Years,” Ophthalmology, 2022; 129(5): 587–590.

2. Gill HK, Niederer RL, Shriver EM, Gordon LK, Coleman AL, Danesh-Meyer HV. “An Eye on Gender Equality: A Review of the Evolving Role and Representation of Women in Ophthalmology,” Am J Ophthalmol, 2022; 236: 232–240. doi:10.1016/j.ajo.2021.07.006