Purpose Our understanding of the pathophysiology of macular hole development has evolved as the diagnostic tools at our disposal have become increasingly sophisticated. Methods Critical review of current published literature regarding pathogenesis of macular hole formation and an appraisal of modern imaging tools such as SD-OCT, SLO-microperimetry in diagnosis and prognostication. Results Perifoveal PVD with vitreomacular adhesion and vitreoschisis allow cortical vitreous to remain on the retinal surface and act as a scaffold for cell proliferation.The presence of a contiguous photoreceptor inner/outer segment (IS/OS) line indicating well-restored photoreceptor cells is increasingly becoming a measure of functional success. Combined SD-OCT and SLO microperimetry studies suspect that ILM peeling may reduce retinal sensitivity. Conclusions Macular hole size seems to be among the best prognostic factors available, however several computerised algorithms as well as the presence or absence of an intact IS/OS layer may correlate with visual outcome. Changes in retinal morphology such as the length of the foveal cone outer segment tips line defect may prognosticate visual acuity after macular hole closure.