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PURPOSE To report on the 15-year incidence of primary angle closure disease (PACD) among participants ≥ 40 years in rural southern India DESIGN: Population-based longitudinal incidence rate study SETTING: 3 rural study centres STUDY POPULATION: Phakic participants aged 40 years or more who participated in both examination time points OBSERVATION PROCEDURES: All participants at the baseline and at the mean 15-year follow-up visit underwent a detailed interview; anthropometry; blood pressure measurement, and comprehensive eye examination. Automated perimetry was attempted based on predefined criteria. MAIN OUTCOME MEASURES Development of any form of PACD, as defined by the International Society for Geographical and Epidemiologic Ophthalmology (ISGEO), during the follow-up period in phakic participants, who did not have the disease at baseline RESULTS: We analyzed data obtained from 1197 (81.4% out of available 1470) participants to calculate the incidence of the disease. The mean age (standard deviation) of the study participants at the baseline was 50.2 (8.1) years; 670 (45.5%) males and 800 (54.4%) females. The incidence rate per 100-person years (95% confidence interval) for Primary angle closure suspect; Primary angle closure; and Primary angle closure glaucoma was 8.8 (8.4, 9.2); 6.2 (5.9, 6.6); and 1.6 (1.4, 1.8) respectively. Thus, the incidence of all forms of PACD was 16.4 (15.9, 17) per 100-person years. On logistic regression analysis, female sex was a significant risk factor while presence of myopia was protective. CONCLUSIONS This study reports long term incidence of PACD from rural India. It has implications for eye health care policies, strategies, and planning.