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Purpose The Andhra Pradesh Eye Disease Study III (APEDS III) is a 15-year follow-up of participants examined in APEDS I. The aim of the study was to report the 15-year incidence of cataract surgery and its associated factors among rural populations.Methods This population-based longitudinal cohort study was conducted in three rural regions of the Indian state of Andhra Pradesh. Data on demographics, ocular and systemic history and risk factors were collected at both baseline and follow-up. Cataracts were classified into pure forms (nuclear, cortical, posterior subcapsular cataract (PSC)) and mixed cataract. Cataract types were defined using baseline assessment. Incidence of cataract surgery was defined as cataract surgery performed in either eye during the 15-year follow-up period among participants who did not have cataract surgery at baseline.Results In total, 2576 (47.7%) of 5395 participants aged 30 years and above at baseline were included, with a mean age of 42.9 years (SD±9.9) and 45% were men. The 15-year crude incidence risk of cataract surgery was 17.5% (95% CI 16.0% to 19.0%) and rate was 17.7 per 100 person-years (95% CI 17.3 to 18.1). In multivariable logistic regression, the incidence of cataract surgery was significantly higher among older adults (OR 11.09; 95% CI 6.92 to 17.78 in 60 years and above), participants with diabetes mellitus (OR 3.27; 95% CI 1.18 to 9.08), those with pure nuclear cataract (OR 2.27; 95% CI 1.56 to 3.30), pure cortical cataract (OR 3.22; 95% CI 1.79 to 5.79), pure PSC (OR 14.70; 95% CI 6.25 to 34.54) and mixed cataract (OR 6.60; 95% CI 4.13 to 10.55).Conclusions Our study found a significantly higher incidence rate of cataract surgery in rural south India. Targeted interventions are needed to enhance eye care services further and improve access to surgical care.