Coral reef banks may form an important component of mesophotic coral ecosystems (MCEs) in the Caribbean, but remain poorly explored relative to shallower reefs and mesophotic habitats on slopes and walls. Consequently, the processes structuring mesophotic coral reef communities are not well understood, particularly the role of disturbance. A large and regionally important mesophotic system, the Hind Bank Marine Conservation District (MCD), St. Thomas, USVI, was systematically surveyed. Data were used to construct a comprehensive benthic habitat map for the MCD, describe the abiotic and biotic components of the benthos among habitats, and investigate patterns of coral health among habitats. Two-thirds of the MCD (23.6 km2) was found to be dense coral reef (Coral Cover = 24.1%) dominated by the Montastraea annularis species complex. Coral reef ecosystems were topographically complex, but could be classified into distinct habitat types, including high coral banks (35.8% of the MCD) and two large novel coral reef habitat types corresponding to an extremely flat basin (18%) and a highly rugose hillock basin (6.5%), containing thousands of coral knolls (2–10 m high). An extreme disease event with undescribed signs of mortality occurred on 47% of coral reefs and reached a high prevalence in affected areas (42.4% ± 6.3 SE,N = 26). The disease was significantly clustered in the basin habitats of the western MCD (global Moran’s I = 0.32,P < 0.01). Observations of the spatial pattern suggested that the driver was specific to the basin habitats and may have been caused by a coherent abiotic event.