Purpose: To examine the 5-year incidence of pseudoexfoliation (PEX) and monitor changes in related ophthalmologic variables. Design: Population-based, prospective cohort study. Methods: A random sample from the Reykjavik Population Census for persons 50 years and older was used. At baseline 1,045 participants were examined for signs of PEX including peripheral band and/or central shield of exfoliative material on the anterior lens capsule. Five years later, 846 (88.2%) of survivors returned for a follow-up visit. Results: The 5-year incidence of PEX was 3.5% in right eyes only, and 5.2% in either eye. Age increased the risk of 5-year incidence by 5% when looking at 10-year age groups (P = .02); the incidence was higher in female subjects (P = .05) than in male. A total of 27% of clinically asymmetric cases converted to clinically bilateral disease over 5 years. Intraocular pressure increased in the group that developed PEX during the 5 years, but the size of the optic cup increased most in eyes that already had PEX at baseline. Conclusion: This incidence study from Iceland confirms findings from previous prevalence studies that PEX is increasingly common with older age in this population. Earliest changes related to PEX may be subtle and difficult to detect, which may lead to some misclassification. Further study is needed to identify clinical features that can reliably detect patients at risk for developing PEX.