Introduction While Retinopathy of Prematurity (ROP) screening guidelines are well established for premature infants; the timing of exams for extreme micro-premature infants is still somewhat debated. Based on our study we propose ROP screening guidelines for infants under 26 weeks. Methods We used de-identified data from ROP CHECK (Glacier Medical Software, Inc), from 7 community hospitals, over a preceding 7-year period. 507 babies under 26 weeks were included in the study. Timing of reaching aggressive active disease (pre plus, plus, and stage 3 zone 1/ posterior zone 2) was recorded. Findings ROP disease progression based on GA and CGA is shown in Table 1. No baby developed Threshold disease (plus with stage 3 zone 2, plus with stage 2 or 3 zone 1/posterior zone 2, plus or pre plus with stage 3 zone 1/posterior zone 2) prior to 29 weeks. Aggressive ROP was found prior to 31 weeks. On initial exam 9 babies had hazy view bilateral, and 11 unilateral that prevented assessment. Younger babies developed aggressive disease more frequently, than older babies, leading to plus disease and subsequent treatment. Discussion Current AAP guidelines state that the recommended timing for a first exam for infants 22 & 23 weeks gestation at 31 weeks post conceptual age should be considered tentative. We found active and aggressive ROP below at 31 weeks. Timely eye screenings allow for proper staging and treatment. While excessive eye exams can be traumatic to the infant, identifying disease early on allows for parents and examiners to prepare for a procedure. (No parent or examiner wants the first eye exam to be threshold/rush disease with urgent vision threatening consequences.) Limitations of this study should be noted and include that gestational age was based on the recorded information by the neonatologist admitting the baby: how this was determined is not recorded (e.g. LMP, Dubowitz, date of conception, early ultrasound). While not specifically addressed in this study; a large variation of weights for GA, ethnicities, co-morbid conditions, and different management in each hospital could affect disease progression. Likewise, university hospitals may have sicker infants and exams would need to be modified accordingly. Because of the time frame of this study, modification of treatment guidelines, the rapid expansion of the use of Anti VEGF, and the more aggressive treatment of posterior ROP, the incidence and timing should be taken as guideline. Conclusion Based on our findings we recommend for babies 22-25 weeks gestation to consider having their initial eye exam upon reaching 29 weeks postmenstrual age. Thereby identifying aggressive ROP and allowing non emergent treatment and discussions with the family.