Objective: To report macular anatomic abnormalities in eyes with stage 4A retinopathy of prematurity (ROP) that may account for poor visual outcome despite an ophthalmoscopically normal-appearing posterior pole.

Methods: Retrospective case series. Methods: Nine patients (14 eyes). Methods: Nine patients (14 eyes) diagnosed with stage 4A retinal detachments were imaged with optical coherence tomography (OCT) before repair by lens-sparing pars plana vitrectomy. One patient (2 eyes) 2 years after successful lens-sparing vitrectomy for stage 4A detachment with reduced visual acuity underwent fluorescein angiography, fundus photography, and imaging with OCT. Methods: Optical coherence tomography findings.

Results: Preoperative OCT confirmed absence of macular involvement in 12 of 14 eyes. Two eyes demonstrated diffuse intraretinal posterior pole changes. Both eyes of a 2-year-old infant demonstrated a lack of normal foveal architecture on OCT scanning and an absent foveal avascular zone on angiography.

Conclusions: Anatomic macular abnormalities--not immediately apparent ophthalmoscopically--may explain the variability in visual outcome after lens-sparing vitrectomy for stage 4A ROP.