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Primary prevention of retinopathy of prematurity (ROP) is sparingly covered in recent literature but is both possible and highly cost-effective The variation in incidence of ROP between neonatal units (NICUs) in large neonatal networks provides clues as to primary prevention of ROP. Differences in beneficial evidence-based care practices include use of antenatal corticosteroids, labor ward care, use of caffeine, facilitating human milk feeding, improved nutrition, and prevention of sepsis. Recent large trials show oxygen saturation targets should be higher than 85–89% to improve survival of very preterm infants, whilst avoiding fluctuations in oxygenation. Multifaceted quality improvement programs in neonatal networks that focus on using known evidence-based practices and addressing attitudes, knowledge, and clinical biases have resulted in steady improvement in ROP rates over several years. Consistently, better performing NICUs have a positive ‘culture’ that fosters team work, camaraderie, and learning opportunities. In poorly resourced low and middle-income countries (LMICs), increasing awareness of ROP and undertaking data collection are important first steps, and there are several low-cost measures that can be taken to reduce ROP rates. Literature searches were undertaken through PubMed. ROP has a multifactorial etiology, and a multifaceted approach is required for prevention.

Primary prevention of ROP: more can be done in all settings