A retrospective case series links a tissue factor-targeted antibody-drug conjugate carrying MMAE payload (TF-ADC-MMAE) to severe, multifaceted ocular surface toxicity. Five consecutive male patients with metastatic pancreatic adenocarcinoma developed Grade 3 or higher toxicity, with microbiology and metagenomic testing supporting a non-infectious cause. Imaging showed phenotypes spanning persistent epithelial defects and corneal ulceration to meibomian gland dropout and tear film instability, with in vivo confocal microscopy also revealing sub-basal nerve plexus damage. The observed incidence within a broader treated cohort (5 of 116) strengthens the case for proactive ocular monitoring and more explicit mitigation plans during therapy.