PURPOSE: To identify the causative mutation leading to autosomal dominant macular dystrophy, cone dystrophy, and cone-rod dystrophy in a five-generation family and to explain the high intrafamilial phenotypic variation by identifying possible modifier genes. METHODS: Fifteen family members were investigated by detailed ophthalmic and electrophysiologic phenotyping. Mutation screening was initially performed with microarrays that detect known mutations in genes associated with retinal degeneration. Furthermore, the patients' genomic DNA was analyzed by sequencing analysis of PRPH2, ABCA4, and ROM1. RESULTS: Heterozygous mutations were identified in three genes and showed five different combinations within the studied family. All clearly affected family members carried the heterozygous PRPH2 mutation p.R172W. Patients with heterozygous sequence alterations only in ROM1 (p.R229H) or ABCA4 (p.V2050L) showed a mild ocular phenotype and were otherwise asymptomatic. The phenotypic severity of patients carrying the PRPH2 mutation increased with an additional mutation in ROM1. Patients carrying all three mutations were the most severely affected. CONCLUSIONS: Features of a PRPH2-associated phenotype might be modulated by additional mutations in other genes (in this family ABCA4 and/or ROM1) accounting for intrafamilial variability and resulting in a cumulative effect worsening the phenotype. Families showing a variable macular dystrophy phenotype caused by mutations in PRPH2 should be tested for additional mutations in ABCA4 and ROM1, as they may alter the progression of the PRPH2 phenotype. This testing will influence genetic counseling, as patients with additional mutations may be confronted with a faster progression of visual loss.