In Iceland, there is at least 1 horse for every 5 human inhabitants, mostly kept on uncultivated rangelands. Although the Icelandic horse is considered robust compared with other breeds, it is nevertheless susceptible to disease. Few studies have investigated the prevalence of intestinal parasites in horses in Iceland. The purpose of this study was to determine the prevalence of the tapeworm, Anoplocephala perfoliata, in horses in Iceland and to explore associations between intensity of infection and the severity of macroscopic pathological lesions in this population. In addition, the relationship between infection and geographical location in Iceland, horse age, and gender were investigated. The utility of a modified McMaster flotation method for identifying infected horses from fecal samples was also studied. The study sample consisted of 104 horses (aged 1–30 yr) slaughtered in 3 abattoirs in North and South Iceland during June and July 2016. The prevalence of A. perfoliata in the horses was 64.4%, with between 1–131 worms found in infected horses. The pathological changes in the horses associated with infection varied from mild (hyperemia in small areas) to severe (large ulcers and necrotic lesions coated with fibrin), and intensity of infection correlated with the size and type of pathological lesions in the intestines. No statistically significant associations between infection with A. perfoliata and geographical location, horse age, or horse gender were detected. The McMaster egg counting method used here was of very low sensitivity (7.4%) and was concluded to be inadequate for detection of A. perfoliata infection in horses. The prevalence of A. perfoliata in horses in Iceland in this study was found to be relatively high compared with results from many studies performed elsewhere in Europe. This may reflect the lack of treatment of horses in Iceland for this parasite, the environmental suitability for the intermediate mite host, and grazing management practices in Iceland. The high prevalence and association with pathology suggest that diagnosis of infection using a sensitive method, along with appropriate treatment, should be considered for horses in Iceland.