Abstract: Antibody-drug conjugates (ADCs) have propelled cancer therapy into the era of precision medicine; however, their ocular surface toxicity, as a prototypical manifestation of the "on-target, off-tumor" paradox, has emerged as a critical bottleneck constraining clinical benefit. The underlying mechanisms involve pathological processes including target antigen cross-expression, payload bystander effects, and tear film homeostasis disruption, with predominant clinical manifestations of corneal epithelial microcyst-like changes, punctate keratitis, and tear film dysfunction. The management paradigm is shifting from passive intervention to mechanism-driven proactive prevention, emphasizing baseline evaluation, dynamic monitoring, and integrated multidisciplinary management. Heterogeneity in toxicity profiles across distinct ADC agents provides crucial clues for structural optimization of drugs and individualized stratified management of patients. Deepening mechanistic research and establishing radiomics-based early warning systems represent the future direction toward achieving a balance between antitumor efficacy and ocular surface safety.

Key words: Antibody-drug conjugates, Ocular surface toxicity, Precision oncology, Proactive prevention, Integrated multidisciplinary management