Two unrelated premature infants at risk for retinopathy of prematurity (ROP) were discharged home from a neonatal intensive care unit. Appropriately timed ROP examinations were performed in an outpatient setting in a free-standing pediatric ophthalmologist's private office remote from any hospital. The infants developed severe apnea and bradycardia at the end of the ROP examinations. As a result, a new protocol for outpatient ROP screening was developed.