Background/Objective: Small-for-gestational-age (SGA) status constitutes a significant risk factor for adverse neonatal outcomes and predisposes individuals to long-term health complications. Detecting pregnancies at risk early in gestation could significantly improve perinatal outcomes. Recent evidence suggests that ophthalmic artery Doppler assessment in the first trimester may contribute to the prediction of impaired placentation reflected in increased risk for preeclampsia. This study aimed to investigate the association between first-trimester ophthalmic artery Doppler parameters and the subsequent birth of small-for-gestational-age (SGA) neonates. Methods: In this prospective observational analysis, 4054 pregnant women underwent ophthalmic artery Doppler evaluation at 11–13 weeks gestation. Maternal demographics, biophysical and biochemical markers, and ophthalmic artery Doppler measurements of pulsatility index (PI) and peak systolic velocity (PSV) ratio were obtained. Outcomes were classified based on birthweight into the ≤3rd percentile and >3rd percentile and ≤10th percentile and >10th percentile groups. To determine the predictive value of Doppler indices, statistical methods included comparative analyses and the receiver operating characteristic (ROC) curves. Results: The analysis indicated that increased PSV ratio at 11–13 weeks gestation correlated with an increased risk of SGA. The PI was not found to be a significant discriminator between pregnancies complicated by SGA and non-SGA pregnancies. Conclusions: First-trimester ophthalmic artery Doppler assessment offers promise as a non-invasive technique for the early identification of pregnancies at risk for SGA neonates. Further validation through large, multicenter studies is needed to confirm its utility and to standardize its use in clinical protocols.