Thyroid eye disease (TED) is the major extrathyroidal manifestation of Graves’ disease (GD). Treatment choice is based on clinical activity and severity of TED, as evaluated with clinical activity score (CAS) and magnetic resonance (MR) imaging. We aimed to determine the relationship between neutrophil to lymphocyte ratio (NLR), a readily available indicator of systemic inflammation, and clinical and MR imaging parameters in TED patients. 87 consecutive TED patients were included. The average signal intensity ratio (SIR), average extraocular muscle (EOM) diameter, and proptosis of the study eye were extracted from MR images. A baseline NLR ≥2.0 was recorded in 37 (42.5%) patients and NLR <2.0 in 50 (57.5%) patients. TED patients with NLR ≥2.0 were older, had a higher CAS, average SIR, average EOM diameter and proptosis, and a lower serum TRAb level than patients with NLR <2.0 (all p<0.05). All MR parameters showed significant correlation with CAS (p<0.05). NLR correlated significantly with CAS (p=0.001), average SIR (p=0.004), average EOM diameter (p=0.007) and proptosis (p=0.007). Multiple regression revealed a significant correlation between NLR and CAS (P=0.001), average SIR (p=0.029) and proptosis (p=0.037). Cox regression analysis showed that a high NLR at baseline was associated with a worse clinical outcome of TED (hazard ratio 3.7, 95% CI 1.22-11.2, p=0.02), at a median follow-up of 25 months. In conclusion, NLR was correlated with CAS and MR imaging parameters, and was associated with a worse clinical outcome of TED at follow-up in TED patients. Additional prospective studies are needed to validate our findings.