Ocular Surface Toxicity of Antibody–Drug Conjugates: Pathogenesis, Diagnosis, Grading, and Treatment of Ocular Adverse Effects

PURPOSE: The American Society of Cornea and Refractive Surgery Cornea Committee convened to create a brief review of the literature and expert experience of antibody-drug conjugates (ADCs) and their impact on ocular surface health. METHODS: Peer-reviewed publications from 2003 to 2025 were evaluated. The information along with authors clinical experience was used to create a white paper on the current aspects ADC therapy that is relevant to the ocular surface health. RESULTS: There are currently 14 Food and Drug Administration-approved ADCs. By most recent estimates in the literature, there are more than 200 ADCs currently in development, and a significant proportion of them are associated with keratopathy that has unique ocular surface manifestations. Features of ADC-induced keratopathy include corneal pseudocysts, superficial punctate keratitis, refractive shifts, and conjunctival hyperemia. More severe adverse events such as conjunctival hemorrhage, conjunctival scarring, and corneal ulcers are rare. These findings correlate with change in visual acuity and visual quality. Eye care providers need guidance to recognize, understand, and communicate critical features of vision health with referring oncologists. CONCLUSIONS: Given the anticipated surge in oncology patients on ADCs, there is a need for dissemination of information on ocular surface concerns. This review covers key aspects ADC toxicity mechanisms and pathological features on the ocular surface health including strategies to diagnose, grade, and treat disease. It also provides expectations on the eye care provider's role in communication with referring oncologists.