Given the global degradation of shallow-water coral reef ecosystems resulting from anthropogenic activities, mesophotic coral reef ecosystems (MCEs) are gaining attention because they are generally considered a de facto refuge for shallow-water species. Despite their inferred importance, MCEs remain one of the most understudied reef habitats, and basic information on the taxonomic composition, depth range, habitat preferences, and abundance and distribution of MCE taxa is scarce. The processes that structure these communities are virtually unknown. Here, we provide a review of what is known about MCEs community ecology and outline essential gaps in our knowledge of these deeper water coral reef ecosystems. The primary findings of this review are as follows: (1) many dominant shallow-water species are absent from MCEs; (2) compared to shallow reefs, herbivores are relatively scarce, perhaps due to limited habitat complexity at depth; (3) changes in the dominant photosynthetic taxa with depth suggest adaptation and specialization to depth; (4) evidence regarding the importance of heterotrophy for zooxanthellate corals at depth is conflicting and inconclusive; and (5) decreased light with depth, but not temperature, appears to be the primary factor limiting the depth of MCEs. The majority of research done to date has been performed in the Caribbean, where some generalization can be made about the community structure and distribution of MCEs. The larger and more diverse Indo-Pacific remains largely unexplored with no apparent generalizations from the few sites that have been comparatively well studied. For MCEs, large gaps in knowledge remain on fundamental aspects of ecology. Advanced technologies must be harnessed and logistical challenges overcome to close this knowledge gap and empower resource managers to make informed decisions on conserving shallow-water and mesophotic coral reef ecosystems.