PURPOSE To assess the long-term visual outcomes of macular hole surgery and to correlate structural changes on spectral domain optical coherence tomography after surgery with long-term changes in the best-corrected visual acuity. METHODS A prospective study looking at 36 patients who underwent macular hole surgery between 2008 and 2010. The main outcome measure was change in the best-corrected visual acuity from 4 months to 6 months after surgery until the study visit. Changes in optical coherence tomography thickness and the morphology of the ellipsoid layer at the 4-month to 6-month scan were also analyzed. RESULTS Over a mean follow-up of 36 months, the best-corrected visual acuity continues to improve from a median of 20/63 at 4 months to 6 months postoperatively to a median of 20/47 at the final study visit (P < 0.01). There was a median gain of 6.5 letters (logMAR 0.13). Seven of 36 patients (20%) improved from nondriving visual acuity at 4 months to 6 months after surgery to driving visual acuity (≥20/40) at the final study visit. The presence of an intact ellipsoid layer at the 4-month to 6-month postoperative optical coherence tomography scan may represent a trend for long-term improvement in visual acuity (Fisher's exact test, P = 0.07). CONCLUSION The best-corrected visual acuity continues to improve beyond 4 months to 6 months after macular hole surgery. Reconstruction of the ellipsoid layer in the early postoperative period may help predict, which patients are likely to have subsequent long-term improvement in visual acuity. This information may help clinicians counsel patients appropriately and help explain cases of unsatisfactory visual improvement after surgery.