A 2026 Update in DSEK Graft Delivery Techniques and Devices.

PURPOSE: Corneal transplantation has evolved from penetrating keratoplasty to selective component keratoplasty, with endothelial keratoplasty (EK) becoming the preferred treatment for most endothelial disorders. EK offers faster visual rehabilitation, reduced immunologic rejection, and longer graft survival. This review intends to describe various Descemet stripping endothelial keratoplasty (DSEK) graft insertion techniques and devices, clinical outcomes, and surgical ease, to facilitate evidence-based technique selection. METHODS: This review critically appraises graft insertion techniques and devices used in DSEK. The available literature was analyzed with respect to techniques, instrumentation, endothelial cell loss, complications, and visual outcomes. The same is described in a clinical context in a comparative model. RESULTS: Busin glide is the most commonly used method for DSEK graft insertion, followed by the needle insertion technique. Most DSEK graft insertion techniques have been classified into pull-through and push-through. Pull-through techniques are associated with lower endothelial cell loss, quicker graft unfolding, and improved apposition, particularly useful for younger donor tissues with tighter scrolls, however, with some risk of graft slippage or inversion during insertion. Push-through techniques require smaller incisions, use specialized injectors to enable controlled graft delivery, but may be associated with complications such as graft dislocation, extrusion, or mechanical injury related to passage through narrow lumen. CONCLUSIONS: Current evidence does not support the superiority of any single technique across all outcome measures, as robust comparative and long-term data remain limited. Ultimately, technique and device selection are guided by surgeon preference, donor tissue characteristics, and the clinical context.