Purpose: To report the long-term outcomes of lens capsular flap transplantation (LCFT) as initial treatment for large macular holes (MHs). Methods: Thirteen consecutive eyes with large MHs who received LCFT as primary treatment were reviewed retrospectively. All enrolled eyes underwent standard 23-gauge vitrectomy, internal limiting membrane peeling, LCFT, and 15% perfluoropropane tamponade. Autologous whole blood was applied in selected eyes to make the LCT intact. A face-down position maintained for 2 weeks postoperatively. Data including demographic information, medical history, anatomical and functional outcomes, and complications were recorded. Results: The mean preoperative MHs diameter was 979.42 +/- 388.28 mu m. Eight eyes received autologous LCFT, and the other five eyes received allogenic LCFT. Whole blood was applied in seven eyes. The mean follow-up duration was 19.57 +/- 6.24 months (range: 12.0-32.2 months). The macular hole was successfully closed in all cases (13/13). The median best-corrected visual acuity improved from 1.76 (interquartile range, 1.23-1.91) logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,150) preoperatively to 1.16 +/- 0.47 logarithm of the minimum angle of resolution (mean Snellen acuity: 20/290) (P < 0.01) at the last visit. No severe complications were noted. Conclusion: Lens capsular flap transplantation may help to improve the closure rate and visual outcomes in large MHs, which could be an alternative method as primary treatment for large MHs.