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To evaluate the current surgical options available for the management of large (>400 μm), recurrent, or persistent macular holes (MHs).A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and surgical treatments of large, recurrent, or persistent MHs. Based on this review, a comprehensive overview was provided regarding the topic of large, recurrent, or persistent MHs and focused on recent surgical management updates.For large MHs, variations of the inverted internal limiting membrane flap technique demonstrated promising rates of primary hole closure and significant visual acuity improvements. For recurrent or recalcitrant MHs, early repeat vitrectomy with extension of the internal limiting membrane peel remains the most straightforward and optimal surgical technique to achieve secondary closure. Regardless of the surgical approach, the goal of each technique described is to induce or aid in stimulating gliosis within the MH to maximize closure.Despite the high success rate of modern MH surgery, large, recurrent, or persistent MHs remain a challenge for retinal surgeons. This review provides a detailed summary on the rationality and efficacy of current surgical options.