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To document directional reflectivity of fundus lesions in a case of acute macular neuroretinopathy.Case report. Clinical and imaging data from a patient with acute macular neuroretinopathy were reviewed. Imaging comprised infrared scanning laser ophthalmoscopy, optical coherence tomography and flood-illumination adaptive optics images acquired through different entry pupils in the cardinal directions (approximately 2° eccentricity).The patient reported acute bilateral paracentral scotoma revealing dark, wedge-shaped macular plaques which by optical coherence tomography were associated with focal loss of the visibility of the cone outer segment tip and inner/outer segment lines. Comparing scanning laser ophthalmoscopy images taken at different entry points in the pupil showed that macular plaques varied from hyporeflectance to isoreflectance. Cone counts by flood-illumination adaptive optics within plaques and optical coherence tomography features of the cone outer segment tip showed also a strong directional variability, peaking at near-normal values. Within each modality, fusion images showed that directional variability covered most of macular plaques.The characteristic fundus abnormalities of acute macular neuroretinopathy may show a strong directional variability. Our findings suggest that the Stiles–Crawford effect may be an important factor in signs and symptoms of acute macular neuroretinopathy.