The aims of this study were to determine the incidence and severity of retinopathy of prematurity (ROP) using digital imaging screening, confirm findings by indirect opthalmoscopy, and document risk factors of ROP in the neonatal intensive care unit (NICU) of a large tertiary hospital in a developing country. This prospective cohort study included infants with gestational age (GA) ≤ 32 wk, birth weight (BW) ≤ 1,500 g, or older and heavier neonates who were critically ill. Two hundred twenty two eyes (111 infants) were screened with digital imaging (Ret-Cam) and indirect ophthalmoscopy until retinal vascularization was complete or the disease regressed. Perinatal risk factors for ROP were analyzed. The overall incidence of ROP was 18.9 %. The incidence of ROP requiring treatment was 5.4 % (12/222) of the total eyes screened. Lower GA and blood transfusion were independent risk factors associated with ROP by multivariate analysis (p = 0.001, OR = 0.562, 95 % CI = 0.395-0.802, and p = 0.027, OR = 6.11, 95 % CI = 1.22-30.44, respectively). Digital imaging facilitated timely screening and detection of ROP, and enabled transfer of images, allowing early intervention for patients who required treatment.