Same Surgeons, Same System, Different Outcomes: Ethnic Gap in Cataract Surgery Recovery

Cataract surgery is one of the most common and most successful operations in modern medicine, a roughly half-hour procedure in which a clouded natural lens is broken up with ultrasound and replaced with a clear artificial one. Yet a new study from Northern Israel suggests that even when patients of different ethnic backgrounds are treated by the same surgeons, under the same protocols, in the same hospital, their paths to recovery can diverge sharply. The finding, published in Frontiers in Ophthalmology, is stirring debate about what really drives unequal surgical outcomes — and whether equal access to care is enough to guarantee equal results.

Researchers at Ziv Medical Center in Safed, a tertiary hospital serving a region where Jewish and Arab communities live in close geographic proximity, reviewed the records of 251 patients aged 60 and older who underwent cataract surgery during 2023. Of these, 153 were Jewish and 98 were Arab. Every operation was performed using the same standardized phacoemulsification technique on the same Centurion Vision System, carried out by senior attending surgeons or supervised senior residents. On paper, the two groups were remarkably similar: the median age was 73 years in both, and the sex split was nearly identical, with roughly half of each cohort being male.

The team extracted demographic details, comorbidities, cataract types, complications, and best-corrected visual acuity from electronic medical records, comparing outcomes at baseline and again at 30 days after surgery. Statistical analysis was performed with IBM SPSS Statistics version 31, using non-parametric Mann-Whitney tests for continuous variables and chi-square or Fisher’s exact tests for categorical ones. Crucially, the two groups started from the same place: preoperative visual acuity was statistically indistinguishable, with both cohorts showing a median LogMAR of 0.7, corresponding to moderately impaired vision before the operation.

But by 30 days after surgery, the trajectories had separated. Jewish patients achieved a median LogMAR of 0.5, while Arab patients remained at 0.7 — a statistically significant difference that reflects meaningfully better visual recovery in the Jewish cohort. In Snellen terms, the Jewish group’s median acuity improved to roughly 20/40 territory while the Arab group lagged behind. Because both groups began with equivalent vision and were operated on under identical conditions, the divergence points to factors beyond the operating room itself.

The complication data were even more striking. Sixty-six percent of Jewish patients experienced no postoperative complications at all, compared with just 28.6 percent of Arab patients. Corneal edema — swelling of the transparent front window of the eye, the most common early complication of phacoemulsification — affected 43.9 percent of Arab patients versus 15.7 percent of Jewish patients, a difference with a p-value below 0.001. Posterior capsule rupture, a more serious intraoperative complication in which the thin membrane holding the lens in place tears, occurred in 11.2 percent of Arab patients versus 3.3 percent of Jewish patients. Rates of retained lens fragments, posterior capsular opacification, intraocular lens dislocation, and elevated intraocular pressure, by contrast, were statistically similar between the groups.

To test whether these gaps could be explained by measured baseline differences, the researchers ran a multivariable logistic regression adjusting for age, sex, hypertension, and diabetes. Even after this adjustment, Arab ethnicity remained independently associated with postoperative complications, with an adjusted odds ratio of 4.74 — meaning Arab patients were nearly five times more likely to experience at least one complication. Male sex carried a borderline association with complications, and diabetes showed a borderline-significant trend, but neither age nor hypertension reached statistical significance. The persistence of the ethnic signal after adjustment suggests that unmeasured factors — not the variables captured in the chart — are doing much of the work.

One obvious candidate is the comorbidity burden itself. Arab patients in the cohort had significantly higher rates of diabetes, 54.1 percent versus 35.9 percent, and hypertension, 70.4 percent versus 58.2 percent. Diabetes is a well-recognized risk factor for more complex cataract surgery and slower postoperative recovery, and regional epidemiological studies have consistently documented higher diabetes prevalence among Arab populations in Israel. The study authors are careful to note, however, that these lifestyle and dietary patterns were not directly assessed in this study, and no causal inferences can be drawn from the observed associations.

Perhaps the most important conceptual contribution of the paper is how the authors frame ethnicity itself. They emphasize that ethnicity in this context should be understood as a social and structural variable — a marker for differences in comorbidity burden, socioeconomic status, health literacy, healthcare access, and utilization patterns — rather than as an indicator of any biological or genetic difference between groups. This framing aligns with a substantial body of literature on ethnic health disparities in Israel, which attributes such gaps primarily to structural and socioeconomic determinants. In other words, the disparity is real, but it is not about ethnicity per se; it is about everything that travels with it.

The authors also acknowledge significant limitations that temper the findings. The study was retrospective and single-center, restricting generalizability and introducing potential selection bias. Follow-up was limited to 30 days, which may underestimate long-term recovery — corneal edema, the most common early complication, often resolves over weeks to months, potentially narrowing the observed gap over time. Critically, the study lacked standardized preoperative lens grading using the Lens Opacities Classification System III, meaning that denser or more advanced cataracts in the Arab cohort — which require longer phacoemulsification time and greater ultrasound energy — cannot be excluded as a contributor to the higher rates of posterior capsule rupture and corneal edema. Inter-surgeon variation in technique and experience was also not captured, and socioeconomic status, health literacy, and adherence to postoperative eye drops were not directly measured.

Those unmeasured factors may prove decisive. Prior research has linked poor compliance with anti-inflammatory and antibiotic eye drops to higher complication rates, including persistent corneal edema and cystoid macular edema, and differences in health literacy, language proficiency, understanding of postoperative instructions, and cultural patterns of healthcare utilization could all plausibly shape recovery. Delayed presentation and barriers to accessing ophthalmic care before surgery may also play a role, though referral patterns were not assessed. The authors call for multicenter, prospective studies with longer follow-up, surgeon-level data, and objective adherence measures such as medication possession ratios or electronic drop monitors to disentangle these threads. In the meantime, the study delivers a clear message for clinicians and policymakers: achieving equity in cataract care requires more than equal access to the same operating room — it demands attention to the comorbidities, education, adherence, and social circumstances that patients carry with them through the hospital doors.

Subject of Research: Ethnic disparities in short-term visual outcomes and complications after cataract surgery among elderly Jewish and Arab patients in Northern Israel

Article Title: Comparative analysis of cataract surgery outcomes in elderly Jewish and Arab patients from Northern Israel, a retrospective cohort study

Article References: Boqaaiya, S., Nujedat, D., Cohen, Y., Ward, S., Ghnem, E., Sharabi Nov, A., Beiruti Wiegler, K., & Chassid, O. (2026). Comparative analysis of cataract surgery outcomes in elderly Jewish and Arab patients from Northern Israel, a retrospective cohort study. Frontiers in Ophthalmology, 6, Article 1942047. https://doi.org/10.3389/fopht.2026.1942047

Image Credits: AI Generated

DOI: 10.3389/fopht.2026.1942047

Keywords: cataract surgery, ethnic disparities, health equity, corneal edema, posterior capsule rupture, phacoemulsification, visual acuity, diabetes, elderly patients, Israel, ophthalmology, health literacy