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To evaluate the impact of implementing a structured referral and education system on improving screening rates for retinopathy of prematurity (ROP) in a tertiary care referral university hospital in a low- to middle-income country.A retrospective audit was conducted from 2015 to 2023. Initially, ROP screening was inconsistent due to the absence of formal referral pathways and limited awareness among NICU staff and parents. In 2018, a structured process was introduced: NICU staff were trained on ROP screening guidelines, parental counselling was initiated, and educational leaflets were developed. From 2019 onwards, additional interventions included parent seminars, integration of ROP leaflets into discharge packages, administrative coordination for automatic referrals, and standardized ROP follow-up forms.From 2015–2017, only 162 out of 422 eligible infants (38.4%) were screened. After 2018 interventions, screening coverage rose to 66.7% (104/156). Continued improvements in 2019 saw 305/355 infants (85.9%) screened, and by 2020, 97.6% (164/168) were screened. From 2021–2023, 628 out of 636 infants (98.7%) were screened. The few missed cases from 2019 onward were families from out-of-area regions, redirected to local services; follow-up data for these cases were unavailable.The absence of a structured referral process initially led to significant screening gaps. Staff and parent education, automated referrals, and standardised documentation significantly improved ROP screening uptake.A coordinated, multidisciplinary approach can transform ROP care delivery in low- to middle-income countries, significantly reducing missed screenings and enhancing neonatal outcomes.