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Zinc oxide nanoparticles (ZnO NPs) are important semiconductor materials with interesting photo-responsive properties. During the past, ZnO-based NPs have received considerable attention for photodynamic therapy (PDT) due to their biocompatibility and excellent potential of generating tumor-killing reactive oxygen species (ROS) through gentle photodynamic activation. This article provides a comprehensive review of the recent developments and improvements in optical properties of ZnO NPs as photosensitizers for PDT. The optical properties of ZnO-based photosensitizers are significantly dependent on their charge separation, absorption potential, band gap engineering, and surface area, which can be adjusted/tuned by doping, compositing, and morphology control. Here, we first summarize the recent progress in the charge separation capability, absorption potential, band gap engineering, and surface area of nanosized ZnO-based photosensitizers. Then, morphology control that is closely related to their synthesis method is discussed. Following on, the state-of-art for the ZnO-based NPs in the treatment of hypoxic tumors is comprehensively reviewed. Finally, we provide some outlooks on common targeted therapy methods for more effective tumor killing, including the attachment of small molecules, antibodies, ligands molecules, and receptors to NPs which further improve their selective distribution and targeting, hence improving the therapeutic effectiveness. The current review may provide useful guidance for the researchers who are interested in this promising dynamic cancer treatment technology.