Background and Objectives: Since the protective role of ghrelin against high glucose-induced retinal damage was not yet explored, we aimed to investigate the serum levels of total ghrelin (TG), its acylated (AG) and des-acylated (DAG) forms in diabetic retinopathy (DR) patients. Moreover, the correlation between serum ghrelin and neutrophil elastase (NE) levels, enhancing the risk of microhemorrhages, was investigated; Materials and Methods: Serum markers were determined by Enzyme-Linked Immunosorbent Assays in 12 non-diabetic subjects (CTRL), 15 diabetic patients without DR (Diabetic), 15 patients with non-proliferative (NPDR) and 15 patients with proliferative DR (PDR); Results: TG and AG serum levels were significantly decreased in NPDR (P < 0.01 vs Diabetic) and in PDR patients (P < 0.01 vs NPDR). AG serum levels were inversely associated with DR progression (r = -0.83,P < 0.01), serum neutrophils percentage (r = -0.74, P < 0.01) and serum NE levels (r = -0.73, P < 0.01). These were significantly increased in NPDR (P < 0.01 vs Diabetic) and PDR (P < 0.01 vs PDR) groups, positively correlating with DR progression (r = 0.86, P < 0.01). Conclusions: The reduction of circulating AG and its association with the increased risk of microhemorrhages could be considered a novel marker for DR progression.