Objective In this study, it is aimed to present the outbreak analysis of Adenovirus conjunctivitis (AC) that develops associated with medical devices used during retinopathy of prematurity (ROP) examination for retinopathy of prematurity. Materials and Methods In this study; The neonatal AK outbreak that occurred at the Sakarya Training and Research Hospital was retrospectively analyzed. Patient data were obtained from files and infection surveillance records. Bacteriological culture and polymerase chain reaction (PCR) examinations for Adenovirus were performed from the eye swab samples of the patients and ten medical instruments (blepharosta, indirect ophthalmoscope, scleral depressor and 20-28 diopters) used during ROP examination. Results After AK was detected in the eyes of a nurse working in a neonatal intensive care unit (NICU), one inpatient baby and three more babies developed AK. All four babies who developed AK had ROP examination on the same day. It was understood that eye examinations could not be performed with sterile or disposable instruments, disinfection was performed with 10% povidone iodine while passing from one baby's examination to another, and then it was used again in ROP examination. No pathogenic bacteria were grown in the bacteriological culture of eye swab samples. Adenovirus DNA was detected by PCR in eye swab samples of four newborns and nurses and in four devices called blepharosta used for ROP examination. Conclusion AC outbreaks develop in infants hospitalized in the NICU when standard precautions are not followed. Disinfection processes should always be carried out with standardized practices, standards should not be compromised and these practices should be constantly monitored.