Purpose To describe the technique and surgical outcomes of a modified large semicircular inverted internal limiting membrane (ILM) flap in the management of macular holes (MHs) in patients with high myopia. Methods We performed this retrospective study on consecutive patients with MH and high myopia (axial length ≥ 28 mm),who received vitrectomy, a large semicircular ILM flap 4 discs in diameter to cover the MH, incomplete air–fluid exchange, and SF6 gas tamponade. All of the patients maintained an upright position for 2 h postoperatively, followed by either a face-down or upright position for 1 week. Post-operative visual acuity was measured, and MH status was assessed using spectral-domain optical coherence tomography. Results Seventeen highly myopic eyes in 16 patients with a mean axial length of 30.49 ± 0.98 mm and mean age of 62.25 ± 9.40 years were included in this study, including five eyes with foveoschisis and four eyes with chronic MH, two with myopic choroidal neovascularization, and four with MH-associated retinal detachment. The MHs of all patients were successfully closed after a single operation. All of the patients were followed for at least 6 months. The average visual acuity in logarithm of minimal angle of resolution improved from 1.26 ± 0.52 preoperatively to 0.69 ± 0.45 6 months postoperatively ( p  = 0.01, paired t -test). Conclusion A large semicircular inverted ILM flap can close a myopic MH efficiently without the need for a long-term face-down position.